Musculoskeletal Proofreading Exercise
You should find 12 errors.
HISTORY OF PRESENT ILLNESS:
The patient is 35-year-old gentleman who comes in for a full physical. He complains of low back pain for the last few months, particularly in the tailbone area. He has had similar problems previously off-and-on, and in 1993 an MRI was done of the area, which showed a mild defuse annular disk bulge at L5, S1 with possible small posterior disk protrusion. The patient reports he has had left lateral thigh numbness that is worse with standing, and daily low back pain. Both his brother and father had problems with the tailbone requiring surgery. The patient believes they may have had some sort of cyst removed.
PAST MEDICAL HISTORY:
1. Distant history of alcohol abuse. The patient has had no alcohol for 9 years.
2. Internal hemorrhoids found on flexible sigmoidoscopy, 12/93.
3. Coccygeal pain with L5-S1 disk protrusion, as above.
4. Positive family history of coronary artery disease. The patient's father had angioplasty at age 53. He was a smoker. The patient himself has no risk factors.
PAST SURGICAL HISTORY:
None.
MEDICATIONS:
None.
HABITS:
The patient does not smoke or drink alcohol.
FAMILY HISTORY:
The patient's father is 56 with a history of coronary artery disease. The patients mother is 56, alive and well. The patient has one brother, age 30, alive and well.
SOCIAL HISTORY:
The patient is married. He is currently retired after the sale of a start-up company which he began. He is considering working with another start-up company. His wife is an interior designer. He has a daughter, age 2, and enjoys activities with his daughter.
REVIEW OF SYSTEMS:
Non-contributory.
PHYSICAL EXAMINATION:
GENERAL: A healthy-appearing gentleman in no acute distress.
VITAL SIGNS: Height 66-1/2 inches. Weight 155. Blood pressure 118/80. Pulse 64.
HEENT: Pupils equal, round, and reactive to light and accomodation. Extraocular muscles are in tact. Fundi benign. Discs flat. Tympanic membranes are clear. Oral pharynx is unremarkable.
NECK: Subtle with no significant cervical adenopathy or thyromegaly.
LUNGS: Clear.
HEART: Heart sounds regular without murmur.
ABDOMEN: Soft and nontender. No liver or spleen enlargement. No masses.
GENITALIA: Normal circumscribed male without testicular masses or tenderness.
RECTAL:
Not indicated.
EXTREMITIES: No sinuses, clubbing, or edema. There are 2+ radial and dorsalis pedis pulses.
NEUROLOGIC: Grossly nonfocal. Reflexes are intact and symmetrical.
ASSESSMENT:
1. L5-S1 disk disease, documented by MRI (magnetic resonance imaging) in 1993, now with intermittent low back pain, chronic left leg numbness, and pain in the tailbone area; likely related to spinal changes.
PLAN:
1. Will check a lab panel, obtain an MRI of the lumbosacral spine, and refer the patient to orthopedics.
2. Relafen 50-mg tablets, two tablets p.o. daily with food.