[doctor] hey steven so i see that you're here and you've been experiencing some back pain for a while could you tell me a bit about that
[patient] yeah it's been back has been hurting for a while
[doctor] mm-hmm
[patient] for about a couple of years and tried a couple things but nothing seems to work
[doctor] okay so let's start start with what happened did something cause the pain
[patient] i think well i played basketball and i bumped one time and i fell and i hit i think i fell on my back got fell real hard
[doctor] mm-hmm
[patient] so it's been hurting after ever since that
[doctor] okay and then how severe is the pain on a scale of like one to ten
[patient] i think it's around a seven
[doctor] wow okay could you describe it for me is it like sharp is it throbbing
[patient] it it hurts pretty bad it's it's sharp
[doctor] okay
[patient] throbs sometimes
[doctor] and does it radiate
[patient] sometimes it hurts more than others and i'm not sure why
[doctor] and does it radiate anywhere
[patient] yeah it goes down my leg my left leg
[doctor] okay alright
[patient] like my toes get numb a little sometimes
[doctor] wow okay and how about like so hmmm you said it goes down your left leg how about any like are you experiencing any loss of sensation in like the genital or rectal area
[patient] i hope not
[doctor] that's okay i i it's gon na help me isolate like what's what exactly is going on so please do n't feel embarrassed to answer the questions do you have any weakness
[patient] yeah sometimes i try to stand up and and and like i i ca n't go get weak or if i'm standing up for too long
[doctor] okay so would you would you say that there are certain positions that make you feel better or worse
[patient] yeah like lying on my side makes me feel better
[doctor] okay
[patient] yeah
[doctor] and then you said that standing also makes it worse right
[patient] yeah if i stand for a while
[doctor] okay and then have you experienced any like loss of control of like your bladder or your bowels
[patient] yeah i pooped myself once
[doctor] okay so incontinence just once though like over the last two years right it's not like a consistent thing
[patient] no it's not consistent i think i stood up for too long i think i was drinking too
[doctor] okay okay you mentioned earlier that you tried some things in the past like what were they
[patient] so i i had a doc gave me some injections before i'm not sure what they were though
[doctor] okay alright and i see in your chart here that you had physical therapy did you feel that that was effective
[patient] no i feel like i could do them the same exercises at my house like they charged me and like it
[doctor] okay but did the did the exercises help
[patient] i mean i guess a little
[doctor] okay not a so not as effective as we would have liked did they put you on any pain medications
[patient] yeah it was just a white pill i'm not sure what it was
[doctor] okay do n't worry i think i can look that up in your chart i just wan na make sure that we have the story straight alright so i know that you said that you mentioned that you played basketball you know before how how like what's your activity like now
[patient] i mean i sit at home all day
[doctor] okay
[patient] watch tv
[doctor] okay
[patient] so not very active i've gained about eighty pounds the past year
[doctor] okay that's a pretty okay that's a pretty significant weight gain well i i just have a few more questions have you do you know if any of your family members have spine conditions
[patient] i think my fourth cousin has scoliosis
[doctor] okay okay but that's that's a little distant but anybody direct like sister brother mom dad
[patient] i do n't think so i mean i do n't even my dad though
[doctor] okay okay and then do you have a personal history of smoking
[patient] what type of smoking
[doctor] any smoke you do n't have to tell me exactly but
[patient] okay
[doctor] have you smoked
[patient] next maybe that i have n't
[doctor] are you it's okay i'm your doctor i'm not here to judge you i just want to make sure that i'm like you know when the conclusions that we come to and like my assessment and plan for you i need to know this information so one more time do you smoke or have you smoked before
[patient] okay i smoked
[doctor] okay that's fine how much and how often and what was it
[patient] i'm not telling you all that i'm just telling you i smoked
[doctor] okay you have
[patient] too many questions are you the fit
[doctor] i'm your doctor i have to
[patient] are you the fence you sound like the fence next question
[doctor] i'm not a op i promise alright that's fine but let me know are you currently like smoking
[patient] no
[doctor] okay okay i just have to ask alright so i do wan na do a quick physical exam i did review your vitals and like part of why i wan na know about your smoking history is that you are stating kind of low like it looks like you are might be in the ninety five percentile range and so we might need to explore some things
[patient] sent them off yeah
[doctor] pardon
[patient] because i'm fat my cousin was fat too and and he gained a bunch of weight he he had to have oxygen
[doctor] you know honestly there are a few other factors weight gain does n't necessarily help you're right but like smoking has like a stronger impact so but it's okay we can explore like you know other options here i as i listen to your heart you have a regular rate and rhythm i do n't appreciate any murmur on so i'm gon na go ahead and do a back exam i do n't notice any overlying erythema or ecchymosis on your skin so no redness or bruising when i push here on your spine does that hurt okay okay so there is midline tenderness on the l4 l5 disk space with right sided lumbar paravertebral tenderness when you bend forward does it hurt
[patient] yeah it hurts
[doctor] okay and when you bend backward does it hurt
[patient] a little bit
[doctor] okay so pain with lumbar flexion and extension alright and as i raise your leg does this hurt when i raise your leg up
[patient] stop
[doctor] okay so supine straight leg test positive alright just a couple more things on neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome patella and achilles reflexes are symmetrical so i just wanted to make sure that i documented all of that in your chart and in a you can ask me any questions but i did look over the results of the
[patient] what does that mean like am i dying
[doctor] no no no you're not dying but i think we have i think i have a good idea of what's causing your back pain so first let's talk about the mri that you had the results show a disk desiccation a disk bulge with parison paracentral disk herniation resulting in moderate right for neural foraminal stenosis okay
[patient] that's a big word
[doctor] those are huge words it's okay so let me tell you what like what all this means and what we're gon na do like for my assessment and plan so for your problem of chronic lumbar back pain based on your symptoms your exam and reviewing your mri that's consistent with a herniated disk at the l4 l5 with radiculopathy what this means is that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves that's why you feel the tingling in your leg alright so that it's also why you felt pain when i pushed on that area so i'm gon na recommend some a spinal injection with a strong anti-inflammatory medication called a corticosteroid right i think you said that you had one before but i think this is something
[patient] i had to have someone hold me down i do n't like needles so do you can i take a pill i do n't want that
[doctor] we could yeah we could give you something to help calm down like the anxiety i would just write you a prescription for one and you would take that maybe three hours before you came in for your appointment and then you should feel calm enough to be able to do the injection
[patient] okay
[doctor] alright
[patient] can i get pain pills too
[doctor] can you
[patient] for pain
[doctor] can you get what now
[patient] pain pills
[doctor] so once i inject the cotocoid steroid in the in your spine it's gon na happen under fluoroscopy right and it's going to be it's a it's just a type of of like x-ray sorry to because i need to be very specific in where i do this injection so i say this because you should n't need anymore pain pills after we do this injection it should help with the inflammation and directly target the bulge to help you out so after this injection give it maybe a day and if you say that you're still experiencing pain then we can talk about maybe giving you pain medication but remember before you said it was n't as effective so i think this steroid shot is the best chance that we have
[patient] i'd say it was n't effective
[doctor] okay sorry i i i saw that they gave you strong pain meds but remember you said the white one did you say it was effective
[patient] yeah i said i said the white ones i said they worked
[doctor] okay i'm sorry so alright so maybe when let's okay so what we're still gon na do though we're gon na do the injection and then if it still hurts after that then we can explore that pain medication i do n't want you to have to consistently be on pain medication it's not necessarily like a good long term solution if after we monitor this you still are experiencing pain we are gon na try the pain meds however i would maybe recommend surgery
[patient] i do n't want i know
[doctor] right and so this is we're just gon na try everything that we can before you know before we get to that place
[patient] mm-hmm
[doctor] do you have any questions
[patient] no
[doctor] alright
[patient] when it when is it when am i having this this when do you want me to get this injection
[doctor] okay so you're gon na go to the front and schedule it this is a very quick and common procedure it should only take about an hour we will need to do this note like if this if this is successful we would only maybe do this four times a year so whenever at the front desk go ahead and schedule i think that mine pretty available to be able to help you with this alright any other questions
[patient] no
[doctor] okay thank you

Medical orders:
description: spinal injection corticosteroid
order_type: medication
reason: chronic lumbar back pain