I had the pleasure of seeing the patient for his first visit today who comes in with the chief complaint of right lower back, right lateral thigh, and calf pain of two years’ duration. He is otherwise healthy appearing 67-year-old male with only underlying diagnosis of hypertension that is treated with Zestril 10 mg p.o. q.d. He states that in the past, he has had back pain for over 35 years that has responded well to periodic oral steroid treatment. Over the last six years, he states that he his pain has progressed to what he described as sciatica, back pain, radiating down his buttock area, his lateral right thigh into this calf. He states that his pain is made worse with walking, movement, going upstairs and relieved by lying down, moving forward or just resting or sitting in a chest. The patient describes his pain is 9/10 currently. His symptoms include a stabbing, tingling, burning and some area of numbness particularly in the thigh. The patient states his pain is constant and otherwise has previous excellent health. He has no prior surgeries. No allergies.
Lisinopril 10 mg p.o. q.d. and one aspirin 325 mg.
He does not drink alcohol but he does smoke 15 cigarettes a day. He uses no recreational drugs. The patient is retired from business and has been retired for multiple years. He states he highly recommends retirement. He is active in sports all his life and states he has had a lot of wear and tear injuries. He has not worked since two years ago. The patient has a significant other and he does have children. His education is graduate level. The patient’s history is significant only for hypertension and the joint pain.
ASSESSMENT AND PLAN:
The is a 67-year-old white male in otherwise excellent shape who has had a long history of low back pain from wear and tear injuries and has been given steroids for that orally on occasion, which have helped. Over the last few years, he has what has developed into a lumbar radicular syndrome and he also was given oral steroids for that and would seem to help but they lasted almost three months ago and he was inquiring as to whether or not he could have more at this time. He states he has had physical therapy in the past and it has not been helpful. He is not interested in that nor interested in chiropractic treatment. My plan is to have him come in for a nerve conduction study, electromyelogram, and also he bring in the results of his MRI from a year ago so that I can review them and talk to him about whether or not he is a candidate for transforaminal epidural steroid at L5 and/or at L4 on the right hand side.
In the future, he is a candidate for facet injections, medial branch block and radiofrequency rhizotomy on the right hand side and lower lumbar L3, L4 and L5 as well. The patient asked me to renew his prescription for Zestril and I did at this time since his pills were low, but I asked him in the future if he gets his prescriptions filled from his primary care doctor for his usual medicines. The patient is not interested in any opioid or adjuvant medications because he prefers to be active. I will see the patient back for return visit after his EMG/nerve conduction study and we will talk to him about those results and the results of his MRI. He would not be able to find his MRI from the outside center since currently he does not remember. We will have to repeat that lumbar MRI so that I can see whether or not there is spinal stenosis and degenerative disc disease present to help dictate treatment plan.
Diagnostic coding would be 99204 and lumbago 724.2, lumbar thoracic radiculopathy 724.4, lumbar facet syndrome 724.8.