The patient is a 47-year-old male. The patient came in for back pain. He was initially evaluated by Dr. Bruce Allen for back pain for the last 2 days
The patient is a 47-year-old male. The patient came in for back pain. He was initially evaluated by Dr. Bruce Allen for back pain for the last 2 days. He said it was in the mid back, going down to the left knee, with some paresthesias in the feet and numbness in the feet. Movement, remaining still, and laying on a side seem to relieve pain. Lying directly on his back increases the pain. No problems with urination. No fever or chills. No nausea, vomiting, or diarrhea. No abdominal pain. PAST MEDICAL HISTORY: Significant for back injury. He had anterior fusion of L3-L4 in the past. He has had multiple episodes, about one a month, since the surgery of exacerbation of his chronic back pain. This typical pain pattern with numbness and radiation down the leg, he states, is nothing unusual for the last multiple episodes. He has had no bladder or bowel dysfunction. SOCIAL HISTORY: He is a smoker. OBJECTIVE: The patient is alert, in no acute distress, obviously uncomfortable however. C-spine is negative. He is tender over the mid back, L2 through L4, with paravertebral muscle spasm that is palpable, also quite tender. Decreased range of motion. The
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