Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Back & Leg Pain
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.ALLERGIES:
She is allergic to sulfa medications.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.ASSESSMENT AND PLAN:
The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.
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.
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,
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