DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Low back pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man known from previous admission in surgery. This patient has a history of HIV with AIDS. He is currently admitted for initiation of methotrexate chemotherapy for lymphoma. He is status post resection of this mass. The patient reports a history of low back pain. He has had this off and on chronically but it has gotten somewhat worse over the past few months. This pain is concentrated in the region of the lumbosacral junction or just above and radiates down the right lower extremity. This perhaps approximates in L4 and/or L5 dermatomal distribution. Nonetheless, he is still ambulatory. He denies weakness. He denies sensory loss. He denies changes in bowel or bladder function. Due to this complaint, an MRI scan of the lumbosacral spine was obtained, and neurosurgical consultation was requested. The patient denies changes of bowel or bladder function or saddle anesthesia.
PAST MEDICAL HISTORY: The patient’s past medical history is remarkable, as above, for HIV status with AIDS. He has a history of shingles. He has a history of intracranial lymphoma.
ALLERGIES: The patient has no medical allergies.
REVIEW OF SYSTEMS: Review of systems as indicated in HPI, otherwise noncontributory.
PHYSICAL EXAMINATION: On examination, this man is currently afebrile at 97.2 degrees. Heart rate is 78 with respiratory rate of 18 and blood pressure of 118/60. Neurologically, the patient is awake, alert, and fully oriented in all spheres. His speech is fluent and appropriate. Memory, cognition, and affect are intact. Cranial nerve function is fully intact, II through XII bilaterally. Motor strength testing demonstrates 5/5 strength. Deep tendon reflexes are 1+ and symmetric. He ambulates with a stable gait.
DIAGNOSTIC DATA: Review of this patient’s MRI study of the lumbosacral spine demonstrates significant degenerative changes at L4-5 and to a lesser extent at L3-4. There is no high-grade central canal stenosis. There are disk space and vertebral body endplate signal changes consistent with degenerative change. Again, no high-grade stenosis is evident.
IMPRESSION:
1. Degenerative lumbar disk disease, L4-5 greater than L3-4, without high-grade neural impingement.
2. Multiple acute and ongoing chronic medical comorbidities.
RECOMMENDATIONS: We had a lengthy discussion with the patient regarding his current situation and options for treatment. At this time, there is no indication for emergent neurosurgical intervention. We would suggest pain management evaluation for consideration of lumbar epidural steroid injections and perhaps a rehabilitative physical therapy session to follow. We will discuss this patient’s presentation with his treating neurosurgeon tomorrow. Further followup and treatment for this condition will be provided by the patient’s treating neurosurgeon.
