M2 Admission Note
11/2/2010 2:00pm
CC: Ms. S.S. is a 71 year-old female complaining of bilateral lower back,
buttock, and posterior and lateral leg pain.
Source: The history was provided by Ms. S.S., who appears to be a reliable
informant.
HPI: Ms. S.S. has experienced 4 years of progressively worsening pain in her
lower back, “pinching” in her buttocks, bilateral radiating pain in her posterior
and lateral legs (left > right), and numbness and tingling in both feet. Over the
last 2 months, she has rated her pain as 10/10 and was forced to quit her parttime job in September, stating that she could no longer stand for more than a
few minutes at a time. Ms. S.S. has found minor relief with Aleve. She states
that the pain is worsened by lifting medium to heavy objects (e.g., a gallon of
milk). Ms. S.S. has undergone physical therapy and epidural steroid injections
with minimal to no relief of symptoms. Ms. S.S. has had an MRI showing spinal
stenosis. Dr. Surgeon performed a lumbar laminectomy of L4-L5 on 11/1/10.
PMH: 1) Osteoarthritis
2) Hypertension
3) Hypercholesterolemia
4) Right eye retinal detachment (2000)
Past Surgical History:
1) tonsillectomy at age 10
2) Total hysterectomy (2007)
Meds:
1) “Norvas” (Norvasc?)5mg1 tablet q day
2) Simvastatin 20mg 1 tablet q PM
Allergies: NKDA
Family History:
Father, deceased age unknown, cause unknown
Mother, deceased age 70, cause “lung related”
Sister, deceased age early 50s, car accident, healthy at the
time
Patient has no children
Social History: Ms. S.S. worked as technologist in the pathology department
of local hospital for past 30 years, stopped working in
September 2010 (see HPI).
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Divorced, lives alone
Patient has no history of smoking
Patient has no history of illict drug use
Alcohol: one drink every 1 to 2 months
Review of Systems:
General: no weight changes, fatigue, weakness, fevers or chills
Skin: no rashes, masses, jaundice, bruising, or changes in hair or
nails
HEENT: + right eye blindness, + left eye cataract, no headaches,
diplopia, or visual blurring in left eye; no hearing loss, tinnitus,
vertigo, earache, or discharge; no epistaxis or stuffiness; + goiter,
no sore throat, hoarseness, or dysphagia
Musculoskeletal: + arthritis, + bilateral shoulder pain (left > right),
bilateral knee pain, and low back pain; no gout, cramps, or muscle
weakness
Endocrine: no diabetes, heat/cold intolerance, polydipsia,
polyphagia, diaphoresis, skin color change, or excess hair growth
Pulmonary: no cough, dyspnea, wheezing, asthma, bronchitis,
emphysema, pneumonia, or TB
Cardiovascular: + high blood pressure, “slight” anemia, and
bilateral varicose veins on calves; denies murmurs, orthopnea,
chest pains, palpitations, edema, or recent transfusions
GI: + lactose intolerance; no nausea, vomiting, heartburn, changes
in appetite, bloating, abdominal pain, diarrhea, constipation, gas,
jaundice, hemorrhoids,melena, or hematochezia
GU: no polyuria, hematuria, dysuria, urgency, hesitancy,
incontinence, or urinary tract infection
Neuro: + numbness/tingling in feet bilaterally (left > right), no
headaches, fainting, seizures, paralysis, dizziness, confusion,
memory loss, tremors, or depression
Gynecological: menopause age early 50s
Physical Exam:
General: older, groggy, well-nourished woman, lying in bed,
pleasant and cooperative during exam
Vitals: Temp (not measured), BP = 124/78, HR = 80, RR = 20
Skin: No rashes, lesions, erythema, or bruising
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HEENT: Cranium normal; no occipital, post-auricular, submandibular,
or cervical lymphadenopathy; tympanic membranes unremarkable;
blind in right eye, visual acuity 20/40 in left eye, extraocular movements
intact, right pupil round, unreactive to light and lacks consensual light
reflex, right eye accomodation present; left pupil round, and reactive to
light and accommodation; no sinus tenderness; oral cavity
unremarkable; neck is supple with a small yet palpable goiter, no
tracheal deviation.
Lungs: anterior and posterior fields clear to auscultation bilaterally
Cardiac: regular rate and rhythm. Normal S1 and S2. No
murmurs, gallops, or rubs
Abdomen: Soft, nondistended, nontender, active bowel sounds. No
masses or organomegaly, no costovertebral angle tenderness.
Hysterectomy scar present.
Extremities: No edema, clubbing, cyanosis
Breast, Genital, and Rectal: not conducted
Neuro:
Mental status: alert, fully oriented, answers questions
appropriately
Cranial nerves: II-XII intact bilaterally
Motor: normal tone. Strength 5/5 throughout bilaterally
Sensory: normal vibratory, pinprick, and proprioceptive
sense throughout bilaterally
Problem List:
1) low back, buttock, and leg pain
2) hypertension
3) Hypercholesterolemia
4) Goiter
Assessment and Plan: Ms. S.S. is a 71 female with a history of osteoarthritis,
hypertension, and hypercholesterolemia who presents with four years of
progressively worsening and radiating low back, buttock, and posterior and
lateral leg pain. Status post lumbar laminectomy of L4-L5.
1) Bilateral low back, buttock, and leg pain
Assessment: Differential diagnosis for pain in this region includes lumbar spinal
stenosis, sciatic nerve entrapment, peripheral vascular disease, vascular
claudication, and urinary tract infection. The presence of an infection could be
detected with urinalysis. Although a UTI could cause referred pain to the
patient’s lower back, it is unlikely that it would cause pain in her legs. This
diagnosis also seems unlikely considering the patient’s denial of polyuria,
hematuria, or urgency. Peripheral vascular disease (PVD) or claudication in
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Ms. S.S.’s lower extremities could explain the pain in her legs and tingling in
her feet. She is at risk for PVD considering her age, hypertension, high
cholesterol, and the presence of varicose veins on her posterior legs.
Claudication could be evaluated with an angiography or Doppler ultrasound of
her lower extremities. Pertinent negatives for PVD include no history of
diabetes or smoking, a normal dorsalis pedis pulse, and no subjective feelings
of cold feet. Likely diagnoses include lumbar spinal stenosis and sciatic nerve
entrapment. MRI would be one of the best ways to differentiate between a
central (stenosis or disc protrusion) or peripheral (sciatic nerve) issue. If the
symptoms were caused by sciatic nerve impingement, such as in the case of
piriformis syndrome, improvement would have been expected with the patient’s
more conservative measures like physical therapy. A recent MRI showed
lumbar spinal stenosis in the L4-L5 region of the patient, making this the most
likely cause of her symptoms. This diagnosis is supported by the patient’s
osteoarthritis and subjective complaints of increased pain with standing and
loading. With this diagnosis, the physical exam prior to surgery would have
been likely to find decreased lumbar extension, and in the area of L4-L5
decreased sensation, strength, decreased reflex, and a characteristic pain
pattern in the posterior legs with worse signs unilaterally. Ms. S.S. underwent a
L4-L5 lumbar laminectomy yesterday.
Plan (post-op):
a)
Social work consult: determine possible in-home care since
patient lives alone
b)
Physical and occupational therapy consult
c)
Patient education regarding deep vein thrombosis (DVT): look out
for hard, red, swollen, painful calves or difficulty breathing. If
symptoms develop, patient should go to the ER immediately
d)
Pain management and education about side effects of narcotics
including driving impairment and constipation
e)
Follow up with surgeon in one week
2) Hypertension
Assessment: Ms. S.S. has a history of high blood pressure and is currently
taking Norvasc (5mg) 1 tablet q day. Blood pressure today was 124/78 which
indicates that the patient is likely receiving an sufficient dose of medication.
Plan:
Continue to monitor blood pressure in her PCP’s office and at home to
ensure continued progress
Educate patient on the importance of low sodium diet and exercise
once she is recovered from surgery
3) Hypercholesterolemia
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Assessment: Ms. S.S. has a history of high cholesterol that she currently is
treating with Simvastatin (20mg) 1 tablet q PM.
Plan:
a)
Continue to monitor cholesterol in her PCP’s office
b)
Check liver function tests every 6 months
c)
Educate patient about avoiding grapefruit juice while on medication
d)
Educate patient on the importance of low cholesterol diet and
exercise
4) Goiter
Assessment: Ms. S.S. was told she had a goiter about 3 years ago by her
PCP. It is small, yet palpable during physical exam of the neck. The goiter is
asymptomatic and her PCP feels that at this time it does not warrant treatment.
Ms. S.S. agrees with this assessment.
Plan:
a) Educate patient about possible symptoms including: tight feeling in
the throat, coughing, hoarseness, and difficulty swallowing or
breathing.
b) Follow up with PCP/endocrinologist if any changes noted in order to
assess cause and begin treatment (Synthroid, surgery, etc).
c) Check TSH, Free T4.
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