FOLLOW UP REPORT SAMPLE #1
The patient comes in for follow up of his lupus. He is tolerating the Plaquenil without any difficulties. He had a right knee arthroscopy done and repair of a meniscal tear. He also underwent viscosupplementation, but he is not sure it made much of a difference. His left knee is bothering him and he was told that he needs viscosupplementation there, so he is going to be going back next week for that. He complains of cramping in his right > left hamstring and calf muscles. The Voltaren 75 mg b.i.d. has not helped at all. He complains of pain with weightbearing and has had swelling of his right knee without warmth.
PE: Weight: 244 lbs. BP: 144/88. Pulse: 60. R: 20. Pleasant gentleman in moderate discomfort due to right knee pain. No inflammatory rashes or nodules. No Raynaud’s or digital ulcerations. EOMI, pupils reactive. Mucous membranes normal. Neck: Supple. Lungs: Clear. Heart: Regular. Abdomen: Soft and nontender. No C/C/E. Cardiopulmonary and abdominal exams are benign. Muscle bulk and strength, touch sensation, and gait are normal. No actively inflamed peripheral joints. No spinous process tenderness. He has moderate degenerative changes of his hands. No actively inflamed peripheral joints. He has a moderate effusion of the right knee with a small Baker’s cyst and moderate right and mild left calf tenderness. Right knee lacks a few degrees of extension. Both hips have good mobility.
2. OP (DEXA 03/10).
3. Bilateral shoulder impingement syndrome.
1. At the patient’s request, after sterile prep, the right knee was aspirated of 46 cc of class I yellow fluid. Synovial fluid analysis is pending. Using ultrasound for guidance the right knee was then injected with 40 mg of Kenalog and 2 cc of 1% lidocaine.
2. Discontinue Voltaren; if he has enough discomfort of his knees he will try Daypro 1,200 mg p.o. q.d. with food.
3. Plaquenil 400 mg p.o. q.d. He has an appointment to see the eye doctor in another few weeks and if his ocular changes persist we will decrease to 200 mg a day.
4. Follow up in 4-6 months, sooner p.r.n.
FOLLOW UP REPORT SAMPLE #2
HISTORY OF THE PRESENT ILLNESS:The patient presents to the office today for a follow-up evaluation of chronic pain in the low back. The patient initially injured his back at work lifting a sign that he states was frozen to the ground. In May of 2008, the patient had epidural steroid injections x 2. He had a reaction that was attributed to the corticosteroids. The patient states that he had relief with the injections. He continued to have pain. The patient describes the pain that he s presently having as a sharp pain in the left lumbar area that radiates down the left lower extremity as far as the foot and toes. He denies any change in bladder or bowel movements.
PAST MEDICAL HISTORY: Significant for DVT in June of 2008.
PAST SURGICAL HISTORY: Denied.
ALLERGIES: PATIENT IS ALLERGIC TO PENICILLINS AND APPARENTLY CORTICO STEROIDS.
CURRENT MEDICATIONS: Tramadol and gabapentin.
PHYSICAL EXAM: The patient is alert and oriented x 3 in moderate distress secondary to chronic low back pain. He ambulates with the assistance of a cane. The patient is 5’8” tall and weighs 280 lbs. Blood pressure today is 120/78. Heart rate is 80. Examination of the lumbar spine reveals patient ambulating with an antalgic gait. Transfers on and off the exam table are difficult for this patient. He has difficultly standing without holding on to the cane. He seems to be favoring the left leg and does not distribute his weight evenly when standing. There is minimal range of motion in all planes. Forward flexion is approximately 25º, extension is 10º and side bending and rotation 10º. The patient has tenderness on palpation of the paravertebral musculature diffusely. Bilaterally there is left SI joint tenderness noted on exam as well. He is unable to toe/heel walk. Straight leg raise is positive on the left at approximately 25º. We were unable to perform Patrick’s exam due to pain. The patient has mild edema noted in the left lower extremity. There is mild motor weakness noted in the left lower extremity as well. Deep tendon reflexes are decreased on the left compared to the right in the lower extremity.
1. L5-S1 anterior listhesis and degenerative facet hypertrophy.
2. EMG shows chronic left L5 radiculopathy).
PLAN: The patient will be scheduled for radiofrequency oblation procedure at L5-S1 facet joint and the patient was advised to contact to the office if further questions or concerns prior to his scheduled procedur.
FOLLOW UP REPORT SAMPLE #3
The patient was last evaluated in our office on May 18th. She has a history of lumbar post laminectomy syndrome and lumbar disc herniation. The pain in the lower back is radiating down the side of the right leg. Pain intensity is rated as a 10/10 and it has been worse over the last few weeks. Her migraines have also become more intense. Her sleeping pattern has been disturbed, sleeping only about two hours in the evening. We are prescribing her MS Contin 60 mg three times a day and Xanax 1 mg two tablets at night. These medications are providing her with about 40% relief at this time.
On examination she is alert and oriented. Manual muscle testing in the upper and lower extremities are 5/5. Sensation was decreased at the right L5-S1 dermatome and the left S1 dermatome. She had 1+ edema in both feet and ankles. Reflexes were +1 at the knees and absent at the ankles. Range of motion was full for flexion and decrease for extension
IMPRESSION AND PLAN:
Patient has lumbar radiculitis, spondylosis, post laminectomy syndrome, and also a history of fibromyalgia and migraine headaches. I am not making any adjustment to her medications. Her medication will be filled through PMC pharmacy and we will see her back in the office in one month.