CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a long history of degenerative disk disease. He states he had an MRI a few years ago that showed a herniated disk at L5-S1. He states he sees Dr. John Doe at the pain clinic. He states he woke up today with increased pain in his left low back. It radiates down to the lateral aspect of his left thigh but does not go past his knee. He has some numbness in this area as well. He describes a burning. He states he did not fall, did not injure himself. He drove himself here to the hospital after he could not get in and get seen at the pain clinic. He denies any bowel or bladder incontinence. The patient denies any abdominal pain, hematuria or dysuria. The patient denies any chest pain, shortness of breath, cough, earache or sore throat.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. Chronic back pain with L5-S1 herniated disk per the patient.
ALLERGIES: None.
CURRENT MEDICATIONS:
1. Ibuprofen.
2. Risperdal.
3. Effexor.
4. Depakote.
5. Zoloft.
SOCIAL HISTORY: The patient smokes tobacco and denies alcohol use.
REVIEW OF SYSTEMS: Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 97.4, pulse 104, respirations 18, O2 sat 100% on room air, and BP 128/82.
GENERAL: The patient is a very pleasant gentleman, does not appear acutely ill.
HEENT: The patient shows no signs of trauma.
NECK: Supple.
CHEST: Shows no retractions.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nondistended, positive bowel sounds, nontender.
BACK: Shows some left-sided paraspinal muscle tenderness in the lumbar region as well as some direct tenderness over the mid lumbar spine. He has no evidence of any swelling or erythema.
NEUROLOGIC: The patient does have a positive straight leg raise on the left. He has diminished reflexes in his patellar region bilaterally. He states this was from prior knee surgery, and he has never had good reflexes. He has just 1+ Achilles reflexes bilaterally. He has good sensation below his knees bilaterally. He has decreased sensation on the lateral aspect of his left thigh compared to his right. He has good strength in all four extremities.
IMPRESSION: Acute exacerbation of chronic low back pain.
PLAN:
1. Given prescription for prednisone to be taken for 10 days.
2. Given also a prescription for Lortab 5, #10.
3. The patient is to recheck with either his family doctor or his pain clinic specialist with any problems.
4. The patient is to certainly return if worse.
