The patient is a 32-year-old male coming in for the first time with the chief complaint of low back pain with some numbness radiating into his left upper thigh laterally and slight anteriorly. Additionally, he is complaining of some pain in his cervical and thoracic upper spine.
He complains of two years duration of low back pain and lower cervical, upper thoracic, and midline spinal pain. The patient complains of pain in his left lower back and pain in the left lateral upper thigh and some pain and numbness in his anterior lower thigh stopping at the knee. He describes his symptoms as aching, numb, and sometimes tingling. His pain is constant. He states that standing or sitting for long time makes his pain worse; lying down and stretching improves it. He has had no treatments thus far except for a couple of our evaluation and possible treatment of chiropractic at the Iselin office. He states that the symptoms have been getting worse and additionally complains of no other pain relieving problems.
My assessment is that this is a 32-year-old male with no back pain localized, likely musculoskeletal in origin. Because he complains of some numbness, we plan on doing a nerve conduction study and electromyelogram to evaluate the nerves of his lower extremities at this time. He will come back for that examination and then for evaluation of those results. At a later time, he may come back for an MRI of his lower back to look for evidence of spinal canal stenosis or other reasons for radiculopathy. Other recommendations would be to consider continue with chiropractic therapy, setting up for physical therapy, swimming, and possible acupuncture in the future. At this time, he is not interested in medication management and I concur with him although we did discuss the kind of treatments possible with medicines including Tylenol, nonsteroidal anti inflammatories, tramadol, and opioids. The patient will return to the clinic for his nerve conduction study and electromyelogram and for evaluation of that subsequently.