Patient Consultation - John Doe

Patient Information

• Name: John Doe
• Date of Birth: 05/15/1980
• Age: 43 years
• Medical Record Number: MRN-123456

Chief Complaint

Patient presents with persistent lower back pain for the past 3 weeks, radiating down the left leg.

History of Present Illness

The patient reports that the pain began approximately 3 weeks ago after lifting heavy boxes at work. The pain is described as sharp and shooting, rated 7/10 in intensity. It worsens with prolonged sitting and improves slightly with rest. The patient has tried over-the-counter pain medication with minimal relief.

Physical Examination

• Vital Signs: BP 128/82, HR 76, Temp 98.6°F, RR 16
• General: Alert and oriented, in mild distress due to pain
• Musculoskeletal: Tenderness over L4-L5 region, positive straight leg raise test on left side
• Neurological: Decreased sensation in L5 dermatome, reflexes intact

Assessment

Lumbar radiculopathy, likely secondary to disc herniation at L4-L5 level.

Plan

1. Order MRI of lumbar spine to confirm diagnosis
2. Prescribe muscle relaxants and NSAIDs for pain management
3. Refer to physical therapy for conservative management
4. Follow-up in 2 weeks to review MRI results and assess progress
5. Educate patient on proper lifting techniques and ergonomics