AI-Generated Note

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* This is a sample note without real PHI

| CHIEF COMPLAINT

Severe back pain radiating down the right leg with numbness in the right foot and weakness causing foot dragging.

| HPI

  • Patient reports severe back pain radiating down the right leg for approximately 37 days.
  • Pain has worsened over the last week, initially localized to the back, now radiating down the right leg with some involvement of the left leg.
  • Numbness in the right foot and weakness causing foot dragging reported.
  • Pain described as sharp at times but mostly a dull ache in the back, with an average pain level of 10.
  • Pain also reported to radiate up the spine with some neck involvement.
  • Pain distribution is 50% in the midline back and 50% in the buttocks or down the legs.
  • Numbness reported in the entire leg for approximately 36 days, radiating to the back of the leg, side of the leg, and top of the foot, including the big toe and second and third toes. The patient clarified the numbness is on the whole leg.
  • Symptoms began after lifting a box at work approximately 37 days ago.

| WORK INJURY/MVA

  • Patient reports injury occurred at work while lifting a box on October 30th. The patient was asked to lift the box by their supervisor despite reluctance.

| PRIOR TREATMENTS

  • Chiropractic treatment initiated two weeks ago, provided slight relief.
  • Massage therapy initiated four weeks ago, provided slight relief.
  • Steroid pack administered three weeks ago, reduced pain by approximately 50%.

| ANTHROPOMETRY

  • Height: 5 foot 4 inches
  • Weight: 110 pounds
  • BMI: 18.9 (calculated from height and weight)

| HANDEDNESS

  • Patient is left-handed.

| PAST MEDICAL HISTORY

  • Psoriasis
  • Type 2 Diabetes (controlled with diet)
  • Mast Cell Activation Syndrome (MCAS)

| PAST SURGICAL HISTORY

  • Cervical fusion at C6-C7 several years ago, performed by Doctor Breadmaker.
  • Two knee replacements five years ago
  • Hip replacement seven years ago
  • Kidney transplant last year

| MEDICATIONS

  • Tramadol (50mg) (twice daily), started in the last couple of weeks.
  • Azathioprine (1mg dosage) (daily)
  • Lactulose (10g) (as needed)
  • Prednisone (5mg) (daily)
  • Aspirin (85mg) (daily)
  • Vitamin C (100mg) (daily), taken for MCAS.
  • Quercetin (500mg) (daily), taken for MCAS.

| ALLERGIES

  • Latex (itching)
  • MRI contrast (itching)

| FAMILY HISTORY

  • Two cousins with Factor V Leiden

| SOCIAL HISTORY

  • Past smoker, quit approximately 20 years ago, smoked a pack a day for ten years.
  • Does not consume alcohol.
  • Occasional marijuana use.
  • Diet consists mostly of fruits and vegetables.
  • Does not exercise regularly.
  • Occupation: Home improvement store worker, typically a desk job but occasionally requires manual labor. The patient was asked to lift a box by their supervisor despite reluctance.

| SURGICAL SCREEN

  • Personal or Family History of DVT/PE: Two cousins with Factor V Leiden
  • Personal or Family History of bleeding disorders: No
  • History of MI or Stroke: No
  • History of Cardiac Procedure: No
  • Chest pain or Shortness of Breath: Occasional shortness of breath with exercise, mainly stopped because of chest pain when exercising.
  • Immunosuppressive Agents: Yes, Remicade and Azathioprine
  • GLP-1 Agonists and dosing: No
  • SGLT2 inhibitors: No
  • Anticoagulation/Blood Thinners: No
  • Problems with Anesthesia: No

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