DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Left-sided chest wall pain, rib pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of significant left-sided rib cage pain and chest wall pain since the past one year. She does not recall any specific trauma in that time. Basically, the patient had surgery in that region that involved partial removal of her rib, and the patient explained that it was a benign tumor in the area; this was almost 16 years ago. Approximately two years ago, the patient also had trauma in the same area that resulted in two or three broken ribs in that area. Apparently, she has had some discomfort off and on but not significant or severe. The pain is described as a burning, numbness, discomfort that comes out of the side. It could be with the patient resting or ambulating or with or without physical activity. The pain, when it comes, can reach a level of 10 on a scale of 0-10. The patient states that, so far, all the studies have been negative. The patient on this admission had bone scans, x-rays, and all types of laboratory data, and all have come in negative for any pathology in that area. The patient has been receiving Percocet, Celebrex. She denies any bowel or bladder dysfunction. The patient denies any history of herpes zoster or shingles from the past. The chronic pain service has been consulted for evaluation.
PAST MEDICAL HISTORY: Significant for arrhythmias and chest wall pain. Otherwise, unremarkable.
PAST SURGICAL HISTORY: Hysterectomy and lumbar surgery in the past and also removal of a tumor in the left chest wall area.
MEDICATIONS: Reviewed.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient lives with her son. She denies tobacco or alcohol use.
FAMILY HISTORY: Negative for chronic pain syndrome.
REVIEW OF SYSTEMS: Positive for chest wall pain. Otherwise negative as per the patient information on admission to Florida Hospital/Celebration.
PHYSICAL EXAMINATION:
GENERAL: The patient is a (XX)-year-old female lying in bed supine. She is awake, alert, and oriented. She appears in no acute distress.
HEENT: Normocephalic. Face is symmetric.
NECK: Good cervical mobility.
LUNGS: Clear.
HEART: Regular rhythm.
CHEST WALL: Normal symmetric excursions. Tenderness to palpation in the left-sided lower rib cage area. No deformity observed. No skin lesions observed but certainly the pain follows a pattern approximately from the 7-8th rib to the 10-11th rib on the left. There is a well-healed scar from previous surgery in the left rib cage area.
ABDOMEN: Soft.
EXTREMITIES: Lower Extremities: Negative for sensory or motor deficit. Gait: Able to ambulate without assistance.
PSYCHIATRIC: The patient denies any history of depression or anxiety.
NEUROLOGIC: Nonfocal.
SKIN: Unremarkable.
RADIOLOGICAL DATA: CT of the chest basically negative, other than some alveolar filling, lungs with infiltrates. No mass observed. Bone scan negative.
LABORATORY DATA: Basically unremarkable. Sedimentation rate 26. Potassium 4.2, sodium 137, creatinine 1. White cell count 6.2 and platelets 202.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with left-sided chest wall pain that the patient describes as a burning, numbness-type discomfort. It appears to me to be a neuropathic-type pain, possible nerve entrapment versus neuroma of the intercostal nerves at that level. Taking into consideration that all the radiological data at this time has been negative at that level, the patient does not have a mass, there is no tumor, there is no bleeding, and there is no infection, the patient may benefit from consideration of a diagnostic intercostal block at that level. The patient is ready to be discharged today. The patient is comfortable on the current pain medications. We would suggest the patient be discharged and follow up as an outpatient in the pain clinic for possible intercostal nerve block.
