SOAP NOTE
SUBJECTIVE: The patient is here for followup from the emergency room. She had swelling of her large toe with purple discoloration and progressive pain, which started 3 days ago. She went to the emergency room and was thought to have (1)________. An x-ray was done and was normal. ESR was 60, and a (2)________ was 7.6. The patient was placed on Vioxx, as well as some Percocet, according to patient. She has not taken the (3)________. She has taken the Vioxx 12.5 mg b.i.d. She has had some decreased tenderness and decrease in the discoloration. The toe is still quite painful. The patient is otherwise without any complaints. She states that she is tolerating the Vioxx, with only minimal GI distress. Patient has difficulty taking (4)________.
OBJECTIVE: Extremities: Right large toe has tenderness, with mild (5)________ and some mild purplish discoloration. There is no (6)________. Neurovascular is otherwise intact.
ASSESSMENT/PLAN: Resolving (7)________ arthritic attack. Continue with Vioxx 12.5 mg b.i.d. until pain free. Patient may increase to 25 mg b.i.d. if her stomach tolerates this. She is to not use the foot as much as possible and limit all (8)________. She may use warm moist soaks. Will recheck (9)________ today and reevaluate in 1 week and (10)________. Patient agrees with plan. The patient will return to work in 1 week. Work note given.
Question 2
LUMBAR MRI
HISTORY: Low back pain radiating into the right leg.
INTERPRETATION: The patient has a normal appearance of the (1)________ and the upper lumbar disk levels are well-maintained down to L2-L3. The L3-L4 area shows mild degenerative disk signal with only very slight narrowing. There is a small amount of posterior (2)________ at the L3-L4 interspace which combines with (3)________ and ligamentum (4) ________ hypertrophy to cause a mild degree of central spinal stenosis and lateral recess narrowing.
The L4-L5 area shows moderate narrowing and more focal disk (5) ________ that begins in the midline at the disk space and then just below the disk level extends eccentrically toward the right side. On the T1 axial images, we can see displacement and obscurity of the fat plane around the right L5 nerve root as it branches off. Although the (6) ________ images are not dramatic, I believe as they come over toward the right side that there is a disk herniation that is extending down over the lip of the L4-L5 interspace toward the right side. The L5-S1 area also shows moderate degenerative disk narrowing and a midline central disk protrusion causing approximately a 3 mm (7) ________ defect on the (8) ________ sac in the midline. This L5-S1 disk protrusion could be affecting the S1 or S2 roots as they begin to branch off, but I do not see any localization toward the right at this level. There is some degenerative facet disease at both L4-L5 and L5-S1, but no central spinal stenosis at these levels. The right L4-L5 foramen is compromised by the posterolateral disk herniation and facet change.
IMPRESSION: Mild degenerative disk changes at L3-L4 and a moderate degree of central spinal stenosis at this level, some posterior spurring and facet and ligamentum flavum changes. Focal disk herniation at the L4-L5 level that is eccentric toward the right side and extends a short way below the L4-L5 disk to elevate and obscure nerve roots around the right L5 root as it branches off. There is a mild right L4-L5 (9) ________ narrowing from the posterolateral disk protrusion and facet change, but no definite compromise of the right L4 root.
A central 3 mm disk (10) ________ at the L5-S1 level causing mild mass effect on the thecal sac and S1 roots as they branch off.
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