Lower Back Pain & Radiating Leg Pain

Patient Name: Michael Adams

Date of Birth: 12/15/1980

Gender: Male

MRN #: 123456789

Date of Service: 04/07/2024

---

Chief Complaint

• Lower back pain and radiating leg pain

History of Present Illness

Mr. Adams is a 43-year-old male presenting with lower back pain that radiates down his left leg. He describes the pain as sharp and shooting, exacerbated by prolonged sitting or standing. He denies any recent trauma or fever.

Past Medical History

• Hypertension
• Type 2 diabetes mellitus
• Hyperlipidemia

Medications

• Lisinopril for hypertension
• Metformin for diabetes
• Atorvastatin for hyperlipidemia

Allergies

• None

Social History

• Non-smoker
• Works as an accountant
• Engages in regular exercise

Family History

• Father has hypertension and diabetes
• Mother has osteoarthritis

Review of Systems

• Negative for bowel or bladder changes
• Positive for numbness and tingling in the left leg

Physical Examination

• General: Alert and oriented, in no acute distress
• Musculoskeletal: Decreased range of motion in lumbar spine, positive straight leg raise test on the left side
• Neurological: Decreased sensation in left leg, 4/5 strength in left foot dorsiflexion

Assessment and Plan

1. Lumbar radiculopathy: Prescribe physical therapy for core strengthening and flexibility exercises. Consider imaging if symptoms worsen or fail to improve.
2. Pain management: Prescribe acetaminophen for pain relief. Avoid NSAIDs due to hypertension and diabetes.
3. Diabetes management: Reinforce diet and exercise. Consider consultation with an endocrinologist for further management.
4. Hypertension and hyperlipidemia: Continue current medications Lisinopril for HTN and Atorvastatin for HLD respectively. Follow-up with primary care provider for routine monitoring.

---

Electronically signed by [Provider's Name], MD. Date: 04/07/2024. Time: 16:45.