This change in status would raise concern for CES, spinal fracture, or obstruction d/t tumor. With the new symptoms and confirmed urinary retention, I would recommend emergency referral for MRI and medical management.

For this visit I would first inquire about possible red flag differentials including cancer, infection/UTI, cauda equina and upper motor neuron pathology. Key questions would include; frequency/timeline/nature of symptoms, difficulty and/or pain urinating, recent signs of infection (fatigue, night sweats, fever), unrelenting night pain, saddle paresthesia’s, flank pain, unexpected weight loss, unilateral or bilateral LE pain/weakness/sensation loss, and individual/family history of cancer. If I suspected cauda equina or UMN pathology I would proceed with a neurological screen (dermatome, myotome, reflexes, UMN testing and cranial nerve testing). Based on the information currently provided in the prompt my differential would include cancer (kidney, bone), infection (spinal, kidney/UTI), and cauda equina. With these differentials I would likely refer this patient to the ER for advanced imaging to rule out serious pathology before proceeding with treatment.