Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Orthopedic Consult - 1
Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.
(Medical Transcription Sample Report)
The patient comes back to see me today. She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome. Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1. She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004. She was last seen on 04/08/2005 with recurrent pain in her low back on the right. Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.
The patient comes back to see me today. She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint. She is also complaining of pain in both knees. She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly. She has not had any x-rays for quite some time. She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms. She is also taking Celebrex through Dr. Sí office.PAST MEDICAL HISTORY:
Essentially unchanged from my visit of 04/08/2005.PHYSICAL EXAMINATION:
General: Reveals a pleasant Caucasian female.
Vital Signs: Height is 5 feet 5 inches. Weight is 183 pounds. She is afebrile.
Neck: Shows functional range of movements with a negative Spurling's.
Musculoskeletal: Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.
Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.
Spine: Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint. She has no other major tenderness. Spinal movements are limited but functional.
Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensation is intact to pinprick.FUNCTIONAL EXAMINATION:
Gait has a normal stance and swing phase with no antalgic component to it.IMPRESSION:
1. Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.
2. Improved, spinal right L3-S1 radiofrequency ablation.
3. Right sacroiliac joint sprain/strain, symptomatic.
4. Left lumbar facet joint syndrome, stable.
6. Right thoracic facet joint syndrome, stable.
7. Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.
8. Degenerative disc disease of both knees, symptomatic.
9. Pes anserinus bursitis, bilaterally symptomatic.
10. Chronic pain syndrome.RECOMMENDATIONS:
Dr. XYZ and I discussed with the patient her pathology. She has some symptoms in her low back on the right side at the sacroiliac joint. Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy. She is also having pain in both knees. We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally. I explained the rationale for each of these injections, possible complications and she wishes to proceed. In the interim, she can continue on Lortab and Celebrex. We will plan for the follow up following these interventions, sooner if needed. She voiced understanding and agreement. Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.
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