Medical Specialty:
Pain Management

Sample Name: Lower Extremity Pain

Description: Evaluation for right L4 selective nerve root block.
(Medical Transcription Sample Report)

REASON FOR REFERRAL: Evaluation for right L4 selective nerve root block.

CHIEF COMPLAINT: Right lower extremity pain and back pain.

HISTORY OF PRESENT ILLNESS: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. She underwent an L3-4 decompression in Month DD, YYYY by Dr. Stanley Gertzbein for back and bilateral lower extremity pain. Shortly after surgery, she began having pain in the right L4 distribution and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has apparently spondylolisthesis and L4-5 stenosis with right posterior surgical fusion changes evident at both levels. According to Dr. Reitman's notes, she is being sent for an L4 selective nerve root block to rule out whether or not she would be a candidate for a TLIF at L4-5. Her MRI films are reviewed. These reveal grade 2 L4 anterior spondylolisthesis without significant canal stenosis, though she has facet joint arthropathy at this level and dorsal postoperative changes. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4.

The patient complains essentially of pain along the anterior tibia and along the right hip, which his burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently.

OSWESTRY PAIN INVENTORY: Significant impact on almost every aspect of her quality of life.

PAST MEDICAL HISTORY: As per above. Adult-onset diabetes.

PAST SURGICAL HISTORY: Eye surgery, cataract surgery and lumbar decompression.

MEDICATIONS: Lotrel, Diovan, Pravastatin, Toprol, Actos, aspirin.

ALLERGIES: No known drug allergies. No shellfish or iodine allergy.

FAMILY HISTORY: Family history is remarkable for heart disease, cerebrovascular disease, diabetes, and hypertension.

SOCIAL HISTORY: The patient is retired. She is married with three grown children. Has a high school level education. She does not smoke, drink or utilize illicit substances.

REVIEW OF SYSTEMS: A thirteen-point review of systems was surveyed and is otherwise negative. The patient denies any other constitutional symptom.

PHYSICAL EXAMINATION: Temp 97.7, pulse 78, BP 143/80. The patient walks with a slight forward stooped gait. There is no spasticity or ataxia. She has mild antalgia after a few steps to the right lower extremity. She has limited lumbar flexion, lumbar extension and right ipsilateral bending with provocable right leg pain. There is no clear pelvic asymmetry. Her gait is forward stooped.

Head is normocephalic and atraumatic. Cranial nerves II through XII are grossly intact. There is no occipitalgic tenderness. The neck is supple with a slight limitation of cervical extension and lateral bending. She has a cervicothoracic kyphotic posture with internal rotation of the shoulders.

Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is obese, nontender, nondistended without palpable organomegaly or pulsatile masses. The skin is warm and dry to touch. There is no cyanosis, clubbing, or edema. Degenerative changes are noted in the joints of the hands, knees and ankles. Brisk capillary refill is noted to all nailbeds.

Inspection and palpation of her axial skeleton reveals a well-healed midline lumbar scar with slight bony step-off evident at the upper edge of the scar. No skin tags or clefts are noted. There is mild lumbar paraspinous hypertonicity, which appears to be more prominent on the right. There is mild midline tenderness over the surgical scar, as well as mild PSIS tenderness.

Motor and sensory examination of the lower extremities is intact. She has hypoactive, but elicitable upper and lower extremity reflexes, though no Achilles reflexes can be elicited. Upper extremity range of motion and neurologic exam is within normal limits. No long tract signs are evident. There is no fasciculation, atrophy, or clonus.

In the supine position, straight leg raise testing produces axial low back pain. There is no sciatic notch tenderness and no particular greater trochanteric bursal tenderness.

1. Lumbar spondylolisthesis.
2. Lumbar spinal stenosis.
3. Lumbar radiculopathy.

PLAN: The risks and benefits of right L4 selective nerve root block were discussed in detail with the patient and they include failure of pain relief, need for further procedures, infection, bleeding, damage to the spinal nerves or abdominal viscera, and postdural puncture headaches. She wished to proceed.

Keywords: pain management, selective nerve root block, lumbar radiculopathy, lumbar spinal stenosis, lumbar spondylolisthesis, back pain, extremity pain, lumbar ct, myelogram, postdural puncture, spondylolisthesis, lower extremity, lumbar, lower, asdf,