Consultation Date: Patient’s name: Date birth: Dear Dr. Thank you for referring this interesting 85 years old right handed lady to pain care Clinic at St Catharines for chronic pain assessment and management. HISTORY OF PRESENTING COMPLAINT/S Patient’s main complaint is Low Back Pain. It started in her 40’s and underwent back surgery in 1978. No details are available. She got better for few years but pain has come back. Progressively the severity of pain is increased and it has become more constant. It increase with sitting and relieved by lying down. With respect to patient complaint of back pain, patient reports no bowel or bladder dysfunction, no saddle anesthesia, no weakness, no fever, no weight loss, no night sweats, no immunosupression, no history of carcinoma, no overt trauma, and no IV drug use On an NRS scale the pain rating is 7/10 at its worst, 3/10| at best, on average it is 5/10 and currently the pain is 4/10. Total BPI Interference Score is "44/70 DN4 Score 1/10 Fibromyalgia Rapid Screening Tool: 1/6, not suggestive of diagnosis of fibromyalgia CONSULTATIONS None recently Other Healthcare Professionals: She has done Chiropractic care with some benefit With respect to the patient’s complaint of back pain, the patient reports no bowel or bladder dysfunction. There is no saddle anaesthesia, weakness or radiation reported. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V. drug use, chronic steroid use or substantive night pain.|With respect to the patient’s complaint of neck pain the patient reports no paresthesia, weakness or radiation. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V drug use, chronic steroid use or substantive night pain. The patient’s headache is not associated with nausea, vomiting, photophobia, or phonophobia. There are not reported visual changes or aura. No history of syncope, seizure or head injury. No fever/chills or signs of systemic infection. No history of hypertension. There are no indications of medication overuse headache."] PAST MEDICAL HISTORY Surgical Back surgery 1978 Total knee replacement 2008 Right total hip replacement 2015 Medical: Chronic back Hypertension CAD Atrial Fibrillation Stroke Breast carcinoma FAMILY HISTORY Not significant FUNCTIONAL INQUIRY General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints. PREVIOUS INVESTIGATIONS MRI: MRI lumbar spine- 15/11/2013FUNCTIONAL INQUIRY PAST PAIN MEDICATIONS Robaxacet on as needed basis. CURRENT MEDICATIONS Metoprolol 25 mg BID Irbesartan 75 mg OD Digoxin 0.0625 OD Apixaban 5 mg OD Donepezil 5 mg OD Atrovastatin 40 mg OD Citalopram 10 mg OD Pantaprazole 40 mg OD Vit B 12 1000 mcg OD ALLERGIES Medications: NKDA Environmental: Nil SOCIAL HISTORY The patient is currently widowed and is presently living with her son. She is currently not working. PSYCHOLOGICAL STATUS AND RELATED MATTERS Patient feels depressed and anxious at times, however there is no history of depression or anxiety. Her anxiety score is 0 and depression score is 1. There is no history of suicidal ideation and the patient has had no previous suicide attempts. The patient does not see a psychiatrist. SEXUAL LIFE: Has no problem with sexual life and is not concerned SLEEP: She has no problems with sleep ADDICTION RISK 1.Worsening AM pain: No 2.Maximum ETOH drinks rum twice a week 3.Nicotine None 4.Prescription drugs: Off the street: No. Borrowed: No. 5.Family psychiatric history: None 6.Family History of substance abuse: None 7.History of trauma: Emotional: No; Physical; No; Sexual; No 8.Which of the following recreational or street drugs has the patient used? None 9.Has the patient ever received treatment for drug abuse? No. 10. UDS: All negative Opiate Risk Tool: PHYSICAL EXAMINATION Age: 85 BP 114/67. HR 70. Weight: 75 kgs. Height: 158 cms. BMI: 30 On Examination: Short of breath and in distress, good eye contact, cooperative On physical exam today, I found the patient to be alert and cooperative, well oriented to person, place and time. The communication skills, recent and remote memory are intact. Normal insight and judgment, affect and mood appeared congruent and within normal limits, and was able to follow commands and cooperated with the examination. Body Type is obese and appears conditioned. She is using a cane and her gait is antalgic. Head and Face Exam: Power is normal bilaterally. Sensation to light touch is intact there is no hyperesthesia,hypoesthesia, allodynia. Palpation is non tender Neck Exam Inspection of the neck and cervical spine there is no signs of muscle spasm, muscle wasting, skin changes Palpation: There is no tenderness over spinous process and paraspinous muscles. Range of motion: Full. Cervical compression test did not elicit pain Shoulder Exam Inspection of both exposed shoulders from front and back is normal Palpation revealed no tenderness bilaterally Abuction reduced bilaterally; other movements normal Back Tenderness on palpation There is spot of spinal tenderness present in the thoracic region Spinal tenderness present in the lumbar region. Lumbar spine Range of motion Performed actively and passively, Forward flexion and extension reduced by 20%. Special Testing Lasegue’s sign- SLR reduced on the right side Gaenslen’s test- positive on the right side Piriformis test- positive on the right side Greater trochanteric tenderness present on the right side. Neurologic exam Alert and oriented Bulk, power, and tone normal Deep tendon reflexes over knee and ankle 2+ and symetric Sensation over L4, L5, S1, Obturator and Femoral nerve distributions are within normal limits There is no allodynia, Hypoesthesia or Hyperesthesia over lower extremities. Plantars downgoing Distal pulses of dorsalis pedis and posterior tibialis are palpable Examination of Knees – Normal examination bilaterally
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