Chronic Lower Back Pain Case Summary

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REASON
CHIEF COMPLAINT: Chronic lower back pain.

HISTORY
The patient is a 40-year-old male with chronic lower back pain and radicular symptomatology in the left lower extremity and then the right. The patient underwent epidural steroid injection therapy on 08/18/2016. The patient underwent a right L5-S1 and an S1 transforaminal ESI under fluoroscopic guidance. The patient states that he did fairly well after injection therapy up until 12/2016 when his symptoms began to come back though not nearly as intense as they were before. Previously, he was having the radicular complaints on a continuous basis. Currently, he states that he has the same type of symptoms but they are not present all the time. He also notes that his symptoms may have also gotten worse as a result of a recent urologic surgery that he underwent which required him to be lying on his back with his legs elevated for several hours until the procedure was completed. He currently denies any new changes with regards to his bowel or bladder function or increased pain with Valsalva-type maneuver. No recent fever or infection. No weight loss. No new constitutional symptoms. …show more content…

Weight 195.2 pounds, BP 118/68, pulse rate 63, temperature 97.4, respiration rate 14. The gait once again is not antalgic. He can perform a full squat without difficulty. Single leg squats reveal knee adduction bilaterally, which is mild. Palpation of the lower back shows only mild tenderness at the lower lumbar paraspinals and only at the right sciatic notch, not at the sciatic nerve trunk exit. Motor power in the lower extremities is at the 4+/5 both proximally and distally. Sensation remains diminished in the L5-S1 distribution. Reflexes were present at the knees bilaterally and absent at the right ankle, but now present at the left. Toes were downgoing. The straight leg raising maneuver was negative. The figure-of-four test revealed lower back pain

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