Primary Care Provider Note

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History of Present Illness:

Fred Jones is a 48-year-old male who presents today for evaluation of right hip pain with diffuse radiation into his right thigh and calf. He also notes cramping in the right calf. He does have a history of chronic low back pain but has never experienced hip or leg pain before. The pain started about a couple weeks ago without cause. He took ibuprofen for the first 3-4 days but is unsure if this helped. Pain increases within a few minutes of walking and progressively gets worse. Symptoms are relieved when he sits or lays down. He tried using Biofreeze and a heating pad which made his back feel better but did not help his hip or leg pain. No loss of bowel or bladder. No paresthesia or weakness.

 

He does have a history of a DVT after THA surgery 2 years ago. Has been diagnosed with CML since 2021, follows with oncology.  

 

REVIEW OF SYSTEMS:

Constitutional: Negative for fevers, chills, sweats, fatigue, and malaise.

Skin: Denies any rash.

Eyes: Denies any visual changes or pain.

Ears: Denies any tinnitus, vertigo, or otalgia.

Nose, mouth, throat, and face: Negative for congestion or sore throat.

Respiratory: Negative for cough, wheezing, and shortness of breath.

Cardiovascular: Negative for chest pain, chest pressure or palpitations.

Gastrointestinal: Negative for nausea, vomiting, diarrhea, change in bowel habits, melena, and abdominal pain. + occasional constipation.

Genitourinary: Negative for frequency, dysuria, nocturia, hematuria and urgency.

Musculoskeletal: Negative for myalgias. + Lower back pain, hip pain, leg pain.

Neurological: Negative for headaches, vertigo, paresthesia, or weakness.

Endocrine: Negative for polydipsia, polyuria, polyphagia, or unintentional weight gains/losses.

 

PAST MEDICAL HISTORY:

Diagnosis:

·        Acne vulgaris

·        Anxiety

·        Chronic low back pain

·        CML (chronic myelogenous leukemia)

·        History of DVT (deep vein thrombosis)

·        History of gout

·        History of left THA (total hip arthroplasty)

·        History of tonsillectomy

·        Hypercholesterolemia

·        Hypertension

·        Obesity

·        OSA (obstructive sleep apnea) on CPAP

·        Seasonal allergies

·        Type II DM (diabetes mellitus)

 

CURRENT OUTPATIENT MEDICATIONS ON FILE PRIOR TO VISIT:

·        Atorvastatin 20 mg daily

·        Aspirin 81 mg daily  

·        Ponatinib 45 mg daily

·        Metformin 1000 mg BID

·        Glipizide 5 mg daily

·        Lisinopril 20 mg daily

 

OBJECTIVE:

BP: 126/72

Pulse: 72

Weight: 140.6 kg (310 lbs)

  

General appearance: alert, no distress.

Eyes: conjunctivae/corneas clear.

Ears: normal TM's and external ear canals.

Throat: Oropharynx moist and without lesion.

Neck: supple, symmetrical, trachea midline. No adenopathy or carotid bruit.

Lungs: clear to auscultation bilaterally.

CV: regular rate and rhythm, S1, S2 normal, no murmur.

Abdomen: Abdomen soft, non-tender. BS normal. No masses, organomegaly, or bruit.

Extremities: no lower extremity edema.

Neurologic: Alert and oriented X 3, normal strength, and tone of upper and lower extremities. Normal coordination and gait.

Musculoskeletal: Able to do active ROM without discomfort. Pain with palpation on right paraspinal area on his lower back.

 

 ASSESSMENT/PLAN:

1.     Chronic bilateral low back pain with acute right-sided sciatica

- Likely an exacerbation of patient’s chronic low back pain. No neurological deficits noted. No skin discoloration or swelling. Will obtain D-dimer test given history of DVT. Will obtain Lumbar spine x-ray. If negative, would recommend physical therapy. He is agreeable as below. He is okay to continue with Ibuprofen or Tylenol as directed, taking with food. I offered a prescription for an anti-inflammatory which he declined at this time. I have also recommended heat, ice and topical analgesics as needed for further pain relief.

- D-dimer test: pending

- X-ray of Lumbar Spine: No acute abnormalities

Radiologist report:

Moderate multilevel degenerative disc space narrowing with marginal spurring, most prominent at L4-5, L5-S1. Prominent lower lumbar degenerative facet hypertrophy is demonstrated as well

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- Ambulatory referral to Physical Therapy

- Warm hand off to Physical Therapy

 

-Reviewed diagnosis and plan of care with Fred. All questions answered and supplemental written materials given to take home for review

-Return to clinic if your condition worsens or fails to improve. Fred verbalized understanding and agrees with the plan. 

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Signature: Dr. Pecepe