Consultation Report Sample:

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PATIENT NAME: David Jones
ID NUMBER: 240804
DATE OF SERVICE:  12/01/10
D.O.B.:   

Consultation

CHIEF COMPLAINT: Low back pain, bilateral lower extremity pain of 4-5 weeks duration.

HISTORY OF PRESENT ILLNESS:  This is a 70-year-old male with chief complaint of low back pain and bilateral lower extremity pain.  The patient denies any recent trauma to the low back.  He states that he has been a body builder for the past 30 years and has worked out at the gym on a regular basis.  He has entered in one multiple body building contests.  He states that approximately 3 years ago, he was a using a machine at the gym doing crunches and felt a pop in his low back.  He states that his back has not been the same since then.  However, he was able to continue working out until about 4-5 weeks ago when he states he was unable to get out of bed due to bilateral lower extremity burning in his legs.  He went to see a chiropractor and had some manipulation, which helped somewhat.  He has taken multiple pain medications, NSAID’s and narcotics.  At present, he is taking Percocet.  He states that this has not helped much at all.  He has not been able to return to the gym.  The patient also gives a history of taking a growth hormone that was a black market product from China for an entire year, approximately 4-5 years ago.  He denies any change in bladder or bowel movements.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PAST MEDICAL HISTORY:  Significant for depression and anxiety.

PAST SURGICAL HISTORY:  The patient had a right knee arthroscopy in January of 2002.

SOCIAL HISTORY: The patient denies any alcohol use, denies any smoking history.  He is presently retired.  Prior to retiring, he worked as a massage therapist.  He does this occasionally for friends at the present time.  He is married.  He lives with his wife.  There is no litigation involved in this pain management case. 

FAMILY HISTORY: Parents are deceased.  Mother died of cancer in 2001.  Father died of cardiac disease.

PHYSICAL EXAM: The patient is a 70-year-old well developed, well nourished male in moderate distress secondary to low back pain, as well as bilateral lower extremity pain.  His blood pressure is slightly elevated today at 130/90.  The patient’s pulse is 70.  He is 5’6” tall and weighs 223 lbs  HEENT:  Normocephalic.  Atraumatic.  Extraocular muscles are intact.  Pupils are equal and reactive to light and accommodation.  Neck:  Supple without masses or adenopathy.  Lungs:  Clear to auscultation and percussion bilaterally.  No rales, rhonchi or wheezing is appreciated.  Heart:  Negative S4, positive S1, positive S2, negative S3.  No murmurs or ectopy is appreciated.  Abdomen:  Soft and non-tender to palpation.  Bowel sounds are present in all four quadrants.  GU:  Deferred.  Skin:  Clear.  Pulses:  Bilaterally symmetric in the upper and lower extremities.  No clubbing, cyanosis or edema is noted in the lower extremities.  Sensory Evaluation:  No sensory deficits are noted in the upper or lower extremities.  Motor strength function:  The patient ambulates with a normal gait.  Transfers on and off the exam table are fluid.  There is no motor weakness noted in the lower extremities.  Motor strength testing is bilaterally symmetric and 5/5.  The patient has well defined musculature.  Reflexes are bilaterally symmetric in the upper and lower extremities. 

Focus examination of the lumbar spine reveals the patient ambulating with a normal gait.  Transfers on and off the exam table are fluid.  There is no abnormal list or posturing.  Lumbar lordosis is maintained.  The patient has full range of motion of the lumbar spine in all planes.  He is able to toe-heel walk without difficulty.  Straight leg raise is negative.  Motor strength testing of the lower extremities is 5/5 and symmetric.  The lower extremities are without muscle atrophy.  Skin is warm and dry to touch.  Pulses are intact.  Deep tendon reflexes are bilaterally symmetric. 

DIAGNOSTIC TESTING: The patient had an MRI done on 07/14/08.  MRI findings reveal HNP L4-L5 on the right minimally compressing the thecal sac.  There is an HNP at L3-L4, again, mildly flattening the thecal sac.  There is degenerative disc disease at multiple levels.

CURRENT MEDICATIONS: Celexa 10 mg one daily, Ativan 2 mg one daily, Ambien 12.5 mg one daily, and Percocet 5 mg t.i.d./q.i.d.

DIAGNOSTIC IMPRESSION:  

  1. Degenerative disc disease.
  2. Chronic low back pain.
  3. Lumbar radiculopathy.
  4. HNP L3-L4 and L4-L5.

PLAN:  The patient is in an acute state of pain secondary to a lumbar radiculopathy.  After careful review of his medications and disease status, the patient would most likely benefit from a lumbar epidural steroid injection.  He was advised no aspirin products or NSAID’s products 3-5 days prior to his injections.  At present, he is taking Percocet for pain.  He also understands that the injections may or may not relieve any or all of his pain and the risks include, but are not limited to injection site tenderness, redness, infection, nerve damage or injury, exacerbation of his pain, as well as death.  He has been advised to remain NPO 8-10 hours prior to the injections and to have a driver available to transport him to and from the facility.  He understands the risks and benefits of the procedure and is willing to undergo a lumbar epidural steroid injection tomorrow.  He has been advised of conscious sedation and what that entails.  His questions regarding the procedures were answered to his satisfaction.