Back and leg pain

The patient is a very pleasant 74-year-old gentleman who currently uses a wheeled walker secondary to significant functional disability. Over the last six months, he has had progressively worsening pain in his low back and legs and most specifically from his knee to his heels in the left leg. He is status post one lumbar surgery and two cervical surgeries with the last lumbar surgery being approximately three years ago. He currently is on Coumadin for atrial fibrillation and has recently lost 60 pounds for treatment for congestive heart failure.

He states that his worse pain is when rising from a seated position where he has severe back and leg pain, specifically in the left side of the low back. He presents today for evaluation.

ASSESSMENT:
This is a very pleasant 74-year-old gentleman with low back and leg pain with suspected “neuropathy.” This is consistent with lumbosacral radicular pain of chronic nature in this very pleasant retired ironworker.

IMPRESSION:
1. Chronic lumbosacral radiculopathy.
2. Query peripheral neuropathy.
3. Status post lumbar surgery of unknown type.
4. Status post two cervical surgeries of unknown type of suspected ACDF.
5. Chronic Coumadin for atrial fibrillation.

PLAN:
I spent grater than an hour in direct consultation with patient today. I do feel we need a lumbar MRI with contrast to assess if there is any issue with the prior surgery or any adjacent level disease. We will obtain an EMG of his bilateral lower extremities to assess for chronic lumbosacral radiculopathy. I did start him on Vicodin 5/500 one p.o. q.12h. p.r.n. pain, #45.

We discussed the possibility of taking a wait and see approach versus medication management versus physical rehabilitation modalities versus diagnostic testing versus interventional pain therapies. He would like to move forward with physical therapy for his knees as ordered by his orthopedic surgeon.

In the long run, a trial of neuromodulation will mostly likely serve him best. I did provide him with a handout and a video about the procedure. He is on Coumadin and we will have to take that into account on his risks versus reward basis for a short percutaneous trial. I did handwrite my recommendations for him and I will see him back for follow-up in the next four weeks after his EMG, MRI, and four weeks of therapy for his knee.

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