DEC 02, 2008
HEENT: eyes clear, nares without congestion or drainage, TM without redness or retraction, throat wtihout redness, tonsillar enlargement or other oral lesions. Neck without lymphadenopathy, lungs CTA, heart RPR without murmur.
Back with normal lumbar lordosis, no focal tenderness in lumbar region, some sorenss in lower central sacrum, full ROM, neg SLR and FABER, strength, sensation and patellar/Achilles relexes intact.
ASSESSMENT/DECISION MAKING/PLAN:
1--worsenign low back pain with left leg radiation. suspect foraminal stenosis, might be candidate for ESI. will ck MRI, pt opts for local test with private insurance.
/es/ LYNN M BUDZAK MD STAFF PHYSICIAN, PRIMARY CARE Signed: 12/02/2008 14:32
LOCAL TITLE: PT OUTPT CONSULT NOTE [DT]
STANDARD TITLE: PHYSICAL THERAPY OUTPATIENT CONSULT
DATE OF NOTE: NOV 24, 2008@13:40 ENTRY DATE: NOV 24, 2008@13:4l:Ol
AUTHOR: LOEHRKE,TODD L EXP COSIGNER:
URGENCY; STATUS: COMPLETED
5: Pt seen for initial evaluation on consult from Dr Budzak for low back pain. Onset: 1979 in upper back, 1989 in lower back.
PMH: Abdominal hernia operation in May (had PT for that consisting of leg lifts), has bony tumor on R posterior acetabulum, pelvic pain, bilat foot pain, and R knee arthroscopic surgery for meniscus tear.
Medications reviewed.
No images.
Pt is not a fall risk.
Current Problem; Has chronic low back aggravated with bridging position and upper back pain in area of L scapula. Pt has been unable to determine what irritates his low back.
Pain now at rest 1/10, increasing to 8/10 when flared up last week with radiation into lateral lower legs in LS distribution.
Any numbness/tingling, bowel/bladder changes, abdominal/flank pain, fever, or night sweats? No.
Pain when low back is flared up interferes with walking.
Social/Work History: Pt is not employed. Pt stays busy doing research and engineering for his company with wife. Pt does not participate in a regular exercise program due to multiple issues with shoulder blade pain, foot pain, knee pain.
Pt’s goals (within 2 months): 1. Determine what is causing the pain in his low back. 2. Indep in HEP that prevents further back pain flareups.
0: Standing Posture: R iliac crest 1/2” higher than L.
ForceS analysis: Straight lying fine, hook lying fine, leg lift (knees bent) fine, knees to chest fine, prone fine, prone on elbows produces his pain over sacral body.
Leg length: Supine equal
Pelvis alignment: ASIS supine R lower and forward, PSIS prone R slightly higher (R sulcus shallower) , Ischial tuberosities R slightly higher.
Muscle length: Thomas test (1 jt hip flexors) L p05, R pos; 90-90 hamstrings L lacks 30 deg, R lacks 60 deg; Piriformi: IR L 0-40, R 0-40, ER L 0-80, R 0-80
Special Tests: Slump neg bilat.
Spinal alignment (FRS flexed rotated sidebent, ERS = extended rotated sidebent) : Neutral L5.
Treatment:
MET for anteriorly rotated R innominate. Neutral mechanics restored.
Disc Program Level I: Performed and provided written HEP (2x/day) of hooklying low back presses (20 reps) , prone press-ups through limited range (10 reps) abdominal strengthening with straight lying mini cruches (10 reps) , half-kneeling hip flexor stretch (30 sec each side) , and mule kicks (10 times)
Initial eval x 25 mm
Manual therapy x 15 mm
Therex x 20 mm
DEC 11, 2008
A: Pt presents with back pain, impaired motion, and impaired mechanics consistent with suspected mechanical low back pain due to acute disc. Limited history does not rule out possiblity of acute stenotic sxs or anterolisthesis. Pain when low back is flared up interferes with walking.
Pt tolerated tx well.
Pt’s goals (within 2 months):
1. Determine what is causing the pain in his low back. 2. Indep in HEP that prevents further back pain flareups.
Prognosis for attaining goals is good. Pt agrees with tx plan and expressed intent to perform HEP.
P: Next session with Lori Dissen, PTA for teaching neutral spine position and transverse abdominal stabilization. Add gentle core strengthening in the neutral position. Teach optimal lifting mechanics. If prone on elbows aggravates his back, change to knee-to-chest stretch and straight lying minicrunches.
Visit 3 back with PT for further evaluation of low back pain and initial evaluation of upper back/L scapula pain. Refresher course in transverse abdominus stabilization and making skinny exercise.
Treatment will consist of therapeutic exercise, manual therapy, patient education, neuromuscular re-education, and modalities as needed.
rtc: 1-2 weeks with Lori.
6 visits over 2 months
/es/ TODD L LOEHRKE (APPLETON CBOC)
PHYSICAL THERAPIST
Signed: 11/24/2008 15:08
Receipt Acknowledged By:
11/24/2008 15:13 /es/ LYNN M BUDZAK MD
STAFF PHYSICIAN, PRIMARY CARE
11/25/2008 07:17 /es/ LORI A DISSEN, PTA
PHYSICAL THERAPIST ASSISTANT
11/14/08 14:30
54 y/o MALE presents for evaluation of an acute problem.
5:
was at Mayo recently, bony lesion felt to be a benign intro-osseus lipoma. also has a bony island, he was concerned the bony island might really be prostate CA since PSA can miss up to 15% of Ca.
Has had back pain off an on in past year. two weeks ago had wife massage trigger points in his back and now has pain into both legs.
Allergies:
SULFA DRUGS, METRONIDAZOLE, CIPROFLOXACIN
Active Outpatient Medications (excluding Supplies)
Active Outpatient Medications Status
1) CLOBETASOL PROPIONATE 0.05% TOP SOLN USE MODERATE ACTIVE
AMOUNT TOPICALLY EVERY DAY AS NEEDED
Active Non-VA Medications Status
1) Non-VA TRIAMCINOLONE ACETONIDE 0.025% CREAM MODERATE ACTIVE
AMOUNT TOPICALLY EVERY DAY
2 Total Medications
The above med list was reviewed with pt, and reconciles all meds taken including VA Rx, non-VA Rx, and otc/herbals.