DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Sciatic nerve pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has a long history of chronic sciatic nerve pain, which she states radiates down her left lower leg. The patient states that over the past four days, she has had an acute flare-up. She describes a sharp, burning pain that begins in her buttocks and radiates down into her thigh. She states that it is 7/10 in severity and that it is constant, gradually increasing in severity.
The patient states that she called her primary care doctor multiple times but has been unable to reach him. She states that she is here hoping for an IM pain control and a script. The patient is wheelchair bound at baseline. She had no trauma, no new injury. She denies any incontinence of stool or urine, and she denies any fevers.
PAST MEDICAL HISTORY: Significant for MI, diabetes, coronary artery disease, hypertension, CHF, chest pain, and sciatic nerve pain.
MEDICATIONS: Aspirin, Humalog, Neurontin, simvastatin, Paxil, Lantus, cholestyramine, lisinopril, MVI, and Glucophage.
ALLERGIES: Multiple medication allergies, listed in chart.
REVIEW OF SYSTEMS: Constitutional, neurologic, musculoskeletal as per HPI. Otherwise, 10-point review of systems was done and is negative.
SOCIAL HISTORY: The patient denies any tobacco, alcohol or drugs.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, nontoxic. She is alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure 168/112, heart rate 96, respiratory rate 18, temperature 37.4, and sat 98% on room air, which is normal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Oropharynx is benign with moist mucous membranes.
NECK: Supple, full range of motion, no meningismus.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: The patient has no bony tenderness and full range of motion: No clubbing, cyanosis or edema. She does have some tenderness to palpation over the buttocks, but otherwise has full range of motion.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She was admitted to the emergency room for observation. The patient’s pain was treated with two shots of Dilaudid IM, which she states did resolve her pain. The patient states this is exactly like her chronic and recurrent sciatic nerve injury and pain that she has, without any new symptoms.
MEDICAL DECISION MAKING: The patient has chronic sciatic-type pain. The patient denies any injury. She presents with what she describes as her chronic recurrent pain. We did consider that there could be an acute injury, but the patient had no evidence of trauma. She has no incontinence. She has a normal neurologic exam.
We are not concerned for cauda equina or other spinal cord injury. The patient’s pain is improved. We did give her a small prescription of Norco at her request, as she states she tried to call her primary care doctor multiple times, was unable to reach him, but at this time, she can be discharged home in stable and improved condition.
DIAGNOSIS: Sciatic nerve pain.
