Consult - History and Phy.
Sample Name: Consult - Back & Leg Pain
Description: The patient has been suffering from intractable back and leg pain.
(Medical Transcription Sample Report)
The patient has been suffering from intractable back and leg pain. She is being carefully worked up. Unfortunately, she has 4-level severe lumbar internal disc disruption. Her L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1 discs all reproduce concordant lumbar back pain when pressurized. Her last procedure was diagnostic and therapeutic on 03/29/10. Medication was placed intradiscally after a diagnostic discogram. The intradiscal steroid has helped her back pain tremendously. Her pain has decreased approximately 70% and she is once again playing golf. She has a new paracentral disc herniation at the L3-L4 level that is frankly compressing the L4 nerve root. This disc herniation and lumbar radiculopathy was addressed during the same trip to the OR. Her leg pain is 100% eradicated at this point in time.
Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.
PAST MEDICAL HISTORY: Significant for anxiety disorder.
PAST SURGICAL HISTORY: Foot surgery, abdominal surgery, and knee surgery.
CURRENT MEDICATIONS: Lipitor and Lexapro.
SOCIAL HISTORY: She is married, retired. Denies tobacco or ethanol use.
FAMILY HISTORY: Father died of mesothelioma. Mother gastric problems.
REVIEW OF SYSTEMS: No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.
PHYSICAL EXAMINATION: Physical exam can be found in great detail in the patient's chart.
I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time.
Keywords: consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar,