DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of left sciatica.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman seen in consultation today for the evaluation of left sciatica. The patient reports episodically having this problem for the last eight years or so. However, for the last year, she has noticed pain starting in her middle lower back area radiating around her left hip area, down her left lateral leg to the knee. It sometimes will affect the back of her knee. She has never had pain, which radiates below the knee. If she drives for longer than an hour, she needs to get out of the car and walk around a bit before she can drive any further. Sitting seems to particularly precipitate this pain. She feels better when she is up and moving around. She takes one Flexeril at night, before bed, and sleeps well. She has tried Lidoderm patch in the past, and this does help her pain in her left back and hip area. She does report she is still able to walk on her treadmill every morning. She does less of an incline and less speed than she used to do, but this does not aggravate her pain at all. She denies any numbness or tingling. She has no weakness in her legs. She has had no bowel or bladder problems.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Appendectomy, left hand surgery and breast surgery for atypia.
CURRENT MEDICATIONS: Naproxen 500 mg b.i.d., Norvasc, lisinopril, Allegra, calcium plus D, Zantac p.r.n. and Flexeril 10 mg at bedtime.
ALLERGIES: Latex.
SOCIAL HISTORY: The patient is married. She has three children. She is right-handed. She does not smoke. She drinks two glasses of wine on the weekend. She denies recreational drug use and domestic violence.
FAMILY HISTORY: Hypertension and her mother had uterine and breast cancer.
REVIEW OF SYSTEMS: Not available.
PHYSICAL EXAMINATION: The patient is fully alert and oriented. She is sitting, in no acute distress. Her casual gait is fluent and steady without limp. Lumbar range of motion is full without pain or restriction. Straight leg raise is negative bilaterally. Motor strength testing of the lower extremities is 5/5 throughout. Deep tendon reflexes are 1+ and symmetric at patella bilaterally, trace at ankles bilaterally.
LABORATORY VALUES: Not available.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman with upper left leg radiculopathy. This is most pronounced when she is sitting. She is driving to (XX) the first week of April and is concerned about the lengthy drive. We would like to obtain a lumbar spine MRI to evaluate for any nerve root compression. We plan to see her back after the MRI has been obtained. We did give her a prescription for Lidoderm patches for pain control.
