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Medicine Consultation - 2

CLINICAL HISTORY: The patient is an 82-year-old female who states that on 03/12/06, she tripped and fell over an uneven sidewalk with subsequent injury to the right lower extremity. She was able to walk after the injury, however with pain. She was subsequently seen at an emergency room where she was treated and released. She currently complains of pain on the right side and points to the lower back area extending down the right leg. There is no history of loss of consciousness or dizziness.

PAST MEDICAL HISTORY: Significant for atherosclerotic heart disease.

MEDICATIONS: Coumadin, Fosamax, and Tenormin.

PAST SURGICAL HISTORY: Status post heart surgery many years ago.

PHYSICAL EXAMINATION: She has a slight antalgic gait. She is utilizing a cane for ambulation.Examination of the left lower extremity demonstrates a full motor and sensory exam.

  • Right lower extremity: Straight leg raise is to 45 degrees. There is a negative tension sign. Right knee range of motion is 0 to 120 degrees. There is no focal tenderness.
  • Right hip: Flexion is to 80 degrees. External rotation is to 45 degrees. Internal rotation is 10 degrees.
  • Back: She is tender over the right sacroiliac joint.

IMPRESSION:
1. Lumbosacral radicular pain.
2. Sacroiliac joint dysfunction.

PLAN: The patient will begin physical therapy and she is to return to this office in one month for reevaluation.


 

  
   
 

  

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