Dr. Backstrand Sample 1
CONSULTING PHYSICIAN: Dr. Kenneth Backstrand
DATE OF CONSULTATION: June 14, 2004
Dr. Beretta:
Thank you for asking me to evaluate this patient at the Lee Memorial Hospital pain clinic.
This extremely pleasant, 39-year-old white male comes in for low back pain evaluation. A
brief medical history is as follows:
PAST MEDICAL HISTORY:
hypertension.
Negative for diabetes, emphysema, cardiac problems or
PAST SURGICAL HISTORY: None.
HISTORY OF PRESENT ILLNESS: The patient states that he had an approximately one
and a half year history of low back pain. He seems to relate this back to his being in a
motor vehicle accident while living in Atlanta. At that time, he saw his family physician, Dr.
Wright, for the low back pain. Oral analgesics were prescribed as well as physical therapy.
He also had six injections per week over a six-month period by Dr. Wright. This did help
the pain. Then he moved to Fort Myers, and approximately two months ago the pain flared
up. There was no specific injury or trauma precipitating this new onset of pain. He saw
Shannon York at the Lee Physician's Group - she is a nurse practitioner. An MRI scan was
done, and he was referred to Dr. Aldo Beretta for further workup. Dr. Beretta subsequently
referred the patient to the pain clinic today.
Today, the patient complains of constant low back pain extending into both legs, right
greater than left. The pain is described as dull and achy, extending from the buttocks all
the way down the posterior leg to the calf all the way to the foot. Sitting particularly
aggravates the pain. However, it does awaken him from a sound sleep nightly.
REVIEW OF SYSTEMS: A 10-point review of systems was discussed with the patient and
is on the chart for review if necessary.
PHYSICAL EXAMINATION: Of note, all physical examinations and treatments were done
in the presence of Registered Nurse, Beverly Atchinson. Focus is on the lower extremities.
There is no gross motor deficit of flexors and extensors in lower extremities. There is no
sensory deficit to pinprick in lower extremities. Dorsalis pedis pulses are palpable and
equal bilaterally. Patellar reflexes are 3/4+ equal bilaterally. Straight-leg raising could only
be done to 45 degrees bilaterally and at that level he had some low back pain.
Radiologic Studies: He did have an MRI scan of the lumbar spine which shows disk
bulging at the L5-S1 level.
IMPRESSION: Low back pain secondary to disk bulging at the L5-S1 level.
A lengthy conversation was held with the patient who fully understands the risk,
complications, and alternatives and agrees to a lumbar epidural steroid injection.
PROCEDURE: With the patient was placed in the right lateral decubitus position, the
lumbar skin was prepped in an aseptic manner with a Povidone iodine solution. Lidocaine
1.5% 1 cc skin infiltration at L3-4 level. An 18-gauge epidural needle was used with loss of
resistance to saline technique. No CSF and no paresthesias were elicited during the
procedure. Depo-Medrol 80 mg was easily injected, and the patient tolerated the
procedure well.
The patient is scheduled to return in approximately one week's time for reevaluation for
possible second lumbar epidural steroid injection.
Thank you, Dr. Beretta, for asking me to participate in the care of this patient. Please feel
free to contact me anytime if I can be of further assistance to you for this or any other
patients.
Sample 2
CONSULTING PHYSICIAN:
Kenneth W. Backstrand, MD
DATE OF CONSULTATION:
05/24/2004
REASON FOR CONSULTATION: Dr. Davis I just wanted you to send you a follow up
note on the progress of this patient. He arrives today 5/24/04 at the Lee Memorial
Hospital Pain Clinic for the third of a planned series of three lumbar epidural steroid
injections. He states is “50% better” than he was prior to initiation of treatment. More
specifically, he states that the low back pain is virtually gone, although he continue to
have some pain in the left lower leg and the foot. He is able to carry on with his daily
activities in a much more comfortable manner. More specifically, he is able to drive
sitting upright versus just two weeks ago when he had to sit in an awkward position in
attempt to get comfortable while sitting as he was driving. He continues to work full time
and is quite happy with the progress thus far and is anxious to complete the treatment
course as prescribed.
PROCEDURE: In the presence of Registered Nurse Leslie Thaggard, the patient was
placed in the right lateral decubitus position. The lumbar skin was prepped in an aseptic
manner with a povidone iodine solution. Lidocaine 1.5% 1 cc was used for skin
infiltration at the L3-4 level. An 18-gauge epidural needle was used with the loss
resistance of saline technique. No CSF and no paresthesias were elicited during the
procedure. Depo-Medrol 80 mg was easily injected. The patient tolerated the procedure
well.
PLAN:
1.
The third of a planned series of three lumbar epidural steroid injections is now
completed. No further injections will be necessary at this time.
2.
The patient states he has an appointment with your office and he has been
instructed to keep that appointment.
Thank you Dr. Davis, for asking me to participate in the care of this patient. Please feel
free to contact if I can be of further assistance to you for this or any other patients.
Sample 3
DATE OF CONSULTATION:
May 17, 2004
CONSULTING PHYSICIAN:
Kenneth Backstrand, M.D.
HISTORY OF PRESENT ILLNESS: Dr. Davis, thank you for asking me to participate in
the care of Lynn Bowen at the Lee Memorial Hospital Pain Clinic. This is an extremely
pleasant 33 -year-old, white female who comes in for low back pain and right lower
extremity pain evaluations. A brief medical history follows.
PAST MEDICAL HISTORY: Negative for diabetes mellitus or emphysema, cardiac
problems or hypertension. Positive for hepatitis.
SURGICAL HISTORY: Hepatoblastoma, cholecystectomy, appendectomy. She
previously underwent general anesthesia without complications. She has also had a
tonsillectomy and a Cesarean section and a FOSS.
MEDICATIONS: No prescription medications are taken.
ALLERGIES: Adriamycin.
The patient states that she has had a two month history of low back pain. There was no
specific injury or trauma precipitating this onset. She did stay that she perhaps was
wearing a pair of uncomfortable shoes. That is the only thing that she could think of that
might have precipitated this. In any event, she saw her family physician, Dr. Yallof, who
did a thorough medical evaluation and prescribed oral steroids which did not help much.
She was then referred to Dr. Davis who in addition to doing an EMG and an MRI
prescribed Bextra which again did not help much. She had an MRI scan of the lumbar
spine which shows:
1.
Small central L4-L5 protrusion with associated annular tear moderately
compressing the thecal sac.
2.
Small L3-4 paracentral protrusion, mild compressing the right ventral thecal
sac.
She did have an EMG/nerve conduction study. I do not have the report in front of me at
this time for the results of that.
REVIEW OF SYSTEMS: A ten-part review of systems was discussed with the patient
and is on the chart for review as necessary.
Today she is complaining of low back pain with right lower extremity pain. The pain in
the right leg is described as dull and achy extending from the buttock to the knee, but not
below the knee on the anterior and posterior aspects of the leg. The pain is described
as intermittent. It does not awaken her from a sound sleep at night. Sitting in particular
aggravates the pain. Standing up from a sitting position also aggravates the pain.
PHYSICAL EXAMINATION: A physical examination is done in the presence of
registered nurse, Leslie Thaggart and focuses on the lower extremities. There is no
gross motor deficits, flexors or sensory of lower extremities. There is no deficit to
pinprick of the extremities. Patellar reflex is one out of four ___ bilaterally. Straight leg
raising could be done to 90 degrees bilaterally without causing significant low back pain.
IMPRESSION: Lumbar radiculopathy secondary to disc bulging.
A lengthy conversation was had with Mrs. Bowen who fully understands the risks,
complications and alternatives and she agrees to a series of lumbar epidural steroid
injections.
PROCEDURE PERFORMED: The patient was placed in the right lateral decubitus
position and the lumbar skin was prepped in an aseptic manner with the Povidone iodine
solution and Lidocaine 1.5%, 1 cc was used for skin infiltration over the L3-4 level. An
#18 gauge epidural needle was used with loss of resistance to saline technique. No
cerebral spinal fluid or paresthesias were elicited during the procedure. Depo-Medrol 80
mg was easily injected. The patient tolerated the procedure well.
The patient is scheduled to return one week from today for the second of a planned
series of three lumbar epidural steroid injections.
Thank you for referring Mrs. Bowen. Please feel free to contact me if I can be of further
assistance for her or any other patients.