CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who lifted a heavy box three or four weeks ago and has been having lower back pain. She reports that her leg seemed weak, but she uses a walker and has been using a walker for some time. She reports she has had urinary incontinence for five years that is not new. The pain is worse with movement. She denies any hip pain. She reports sometimes she has some pain shooting down her left leg and presents for evaluation. She reports it occurred three or four weeks ago, got better for a week, and now it is worse again.
PAST MEDICAL HISTORY: Unremarkable.
CURRENT MEDICATIONS: Tylenol.
ALLERGIES: None.
SOCIAL HISTORY: The patient does not smoke and does not drink.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: The patient complains of lower back pain. The pain is worse with movement. No problems with bowel control, but she has been incontinent of urine for five years. She also has some occasional pain shooting down her left leg. Her legs are always weak, seemed little weaker lately, and presents for evaluation as noted. All other review of systems is negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 144/98, temperature 97.8, pulse 96, and respiratory rate 16.
GENERAL: The patient is awake, alert, and is in no acute distress.
HEENT: Pupils are equal, round, and react to light. Extraocular movements are intact.
NECK: Supple.
CHEST: Clear.
HEART: Regular rate and rhythm, no murmurs.
ABDOMEN: Soft, nontender. Bowel sounds are present.
BACK: Tenderness over the lower lumbar spine paraspinal muscles. No spasm.
EXTREMITIES: Has 4+/5 strength bilaterally. Sensation is intact. Deep tendon reflexes are 1+ and equal.
DIAGNOSTIC DATA: LS spine x-ray showed compression fracture of L1 and L3. It is unclear if it is acute or not, a lot of osteoporosis, really hard to get a clear visualization. MRI scan was done to make sure she did not have any cord compression or any serious disk disease, and she has an acute L1-L3 compression fracture without any sign of cord impingement or significant disk disease. She does not want anything for pain in the emergency department. Have the patient follow up in the office and will arrange to see if the patient can get an evaluation by Radiology for possible vertebroplasty.
PLAN:
1. The patient is sent home on Lortab for pain.
2. Follow up with Dr. John Doe.
3. Return if problems.
DIAGNOSIS: Compression fracture of L1 and L3.
