Follow Up Report Sample:
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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.