Dialogue:
Doctor: Good afternoon, ma'am. Before we begin, how old are you?
Patient: Good afternoon, doctor, I'm forty five years young. 
Doctor: Great, and with what race do you identify?
Patient: I'm an African American. 
Doctor: Thank you, what seems to be the problem today?
Patient: It started a while ago. I've had this pain in my left shoulder and neck for the last year and a half.
Doctor: I see, have these symptoms been persistent for the last year and a half? Or do they come and go?
Patient: The pain actually went away all on its own once, but now I have pain in my right foot.
Doctor: Is there any injury that you can remember?
Patient: No, but I started working out really hard in November of two thousand and five. 
Doctor: Have these symptoms progressed? 
Patient: Well, in March of this year I couldn't feel my right foot on the bathroom floor one day, so I immediately called my P C P. 
Doctor: How did your P C P handle this?
Patient: She scheduled an, um, a nerve conduction study. 
Doctor: Do you remember the results of that study?
Patient: I have the report right here, take a look, please.
Doctor: Ah yes, radiculopathy, do you have any numbness or tingling into the legs or feet? 
Patient: Yes, it started tingling in my right middle toe, and then it began in my knees and left middle toe. Then, it even moved into my elbows, which was really concerning. 
Doctor: Did you have any other imagine done? 
Patient: Yes, I had an MRI of the lower back, take a look. 
Doctor: Yes, I see, everything looks normal here, and the report supports that. Okay, do you have any weakness or feelings of instability in the legs? 
Patient: Yes, my legs feel kind of wobbly, like at the knees, and I feel like I can't totally pick up my left leg. 
Doctor: Are these symptoms getting worse?
Patient: Yes, a little bit at a time, but it's definitely getting worse. 
Doctor: Okay, going back to the workouts you were doing, are you sure you can't remember anything that would have set this pain off? 
Patient: No, nothing there. 
Doctor: Are you having any trouble going to the bathroom?
Patient: No, absolutely not, everything is normal. 
Doctor: When you lay in bed, are any positions more comfortable than others?
Patient: No, honestly every position makes it hurt.
Doctor: Okay, and we've already done two M R I s of the neck, and I've talked about those with you, correct?
Patient: Yes, I remember that. 
Doctor: Have you seen another doctor for this pain?
Patient: Yes, I saw another surgeon who wanted to do, um, a decompression procedure. 
Doctor: Do you want to go forward with the surgery?
Patient: No, not really. I'm pretty reluctant to do any kind of surgery.

Clinical note section (GENHX):
The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  This has subsequently resolved.  She started vigorous workouts in November 2005.  In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  She had an MRI of lumbosacral spine, which was within normal limits.  She then developed a tingling sensation in the right middle toe.  Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  She then started getting sensory sensations in the left hand and arm.  She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  Symptoms have been mildly progressive.  She is unaware of any trigger other than the vigorous workouts as mentioned above.  She has no associated bowel or bladder symptoms.  No particular position relieves her symptoms. Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed.  She saw you for consultation and the possibility of surgical decompression was raised.  At this time, she is somewhat reluctant to go through any surgical procedure.