SUBJECTIVE: The patient is a (XX)-year-old male with a history of acute low back pain on and off over the last year. He states that, last May, he felt a pop in his back lifting a heavy object. After that time, he had about a week of low back discomfort, which was treated with muscle relaxants and rest. His symptoms recovered after about a week’s time.
More recently, in the last few weeks, he has had a similar episode of discomfort. Again, he felt another pop in his back. This time, he had a similar episode of low back discomfort. Pain present in the mid low back and spreads up into the mid thoracic region. Recently, the patient was seen by his primary care for this discomfort, about a week ago.
He then states he was lifting another heavy object at his home and felt a similar pull. He then had an episode of about two hours of discomfort where he was unable to move. He was then taken to the emergency room and given IV pain medications and steroids. The emergency room doctor diagnosed him with spasm. The patient says that he had a little bit of tingling in his left great toe at that time. Since Monday, his symptoms have been progressively improving.
He has been using anti-inflammatories, muscle relaxants, and Dilaudid for pain medication as prescribed by the emergency room doctor. He is here today for evaluation. Today, he has a similar low back discomfort. He also has some discomfort above his left iliac crest and some residual soreness in his left hamstring. He has no radiation of pain down the leg.
He has no residual left great toe paresthesias. He has no weakness in the leg. He denies bowel or bladder incontinence. He has not done any of the physical therapy at this time. He continues to take pain medication, mainly anti-inflammatory and muscle relaxant, at night as well as Dilaudid at night for residual discomfort. He has not had any studies for review.
His symptoms are worse again with coughing or bending and twisting and lifting motion. Symptoms seemed to improve with rest.
The patient does have a past medical history of bilateral pulmonary embolism with no known etiology. He is taking Dilaudid 2 mg at night, Zofran 4 mg p.r.n. nausea, ibuprofen 600 mg p.o. t.i.d. diazepam 5 mg p.o. t.i.d. p.r.n. spasm.
Today, he has a similar low back discomfort. He also has some discomfort above his left iliac crest and some residual soreness in his left hamstring. He has no radiation of pain down the leg. He has no residual left great toe paresthesias. He has no weakness in the leg. He denies bowel or bladder incontinence. He has not done any of the physical therapy at this time.
He continues to take pain medication, mainly anti-inflammatory and muscle relaxant, at night as well as Dilaudid at night for residual discomfort. He has not had any studies for review. His symptoms are worse again with coughing or bending and twisting and lifting motion. Symptoms seemed to improve with rest.
The patient does have a past medical history of bilateral pulmonary embolism with no known etiology. He is taking Dilaudid 2 mg at night, Zofran 4 mg p.r.n. nausea, ibuprofen 600 mg p.o. t.i.d. diazepam 5 mg p.o. t.i.d. p.r.n. spasm.
OBJECTIVE: The patient is 6 feet tall and weighs 232 pounds. Blood pressure is 124/90, pulse is 102, respirations are 16. The patient is in no acute distress. He is able to ambulate from sitting to standing position without difficulty. He moves his lower extremities with 5/5 strength with some mild pulling in the low back. Deep tendon reflexes are normoreflexic throughout. He had no beats of clonus present. Sensation is intact in the lower extremities bilaterally.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with history of acute low back pain, which is likely lower lumbar musculoskeletal strain with associated spasm. We do agree with primary care physician’s plan and will have the patient start a course of physical therapy at this time. We have given him a new prescription for physical therapy to start, closest to his home.
In addition, we have given him prescription for a new muscle relaxant, Flexeril #50, to start at this time. With regard to Ambien, instructed the patient that if he needs any refills of this medication, that he should go to his primary care physician. Also instructed him to increase his dose of anti-inflammatory medications from 600 to 800 mg three times a day with food. He should use local measures as well, including heat and ice to the back.
We have instructed him to call if there are any changes in his condition, including lower extremity radiation, paresthesias or weakness, and we have instructed the patient to call us with any concerning symptoms. If there are any questions or concerns, Neurosurgery should be contacted.
