Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Follow-up for lumbar spinal stenosis (LSS) / Worsening of LSS symptoms
History of Present Illness:
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., increased leg pain, weakness, numbness, difficulty walking).
Describe the character, duration, and location of any new or worsening symptoms.
Mention any factors that exacerbate or improve symptoms (e.g., walking worsens pain, sitting provides relief).
Briefly describe any recent falls or injuries.
Past Medical History:
Include the date of lumbar spinal stenosis diagnosis.
Mention the specific level(s) of stenosis if known (e.g., L3-L4, multilevel).
List any relevant past medical history, such as:
Back injuries or surgeries
Underlying medical conditions (e.g., arthritis, osteoporosis)
Risk factors for LSS (e.g., obesity, smoking)
Medications:
List all current medications, including those specifically used for LSS pain management (e.g., NSAIDs, neuropathic pain medications).
Social History:
Inquire about occupation and activities that may impact LSS symptoms (e.g., prolonged standing, lifting).
Family History:
Not typically relevant for LSS, but can be included if pertinent (e.g., family history of arthritis).
Physical Exam:
General observation: Assess posture, gait, and any signs of discomfort.
Spine exam: Look for tenderness, deformity, or range of motion limitations.
Neurological exam: Evaluate muscle strength, sensation, and reflexes in the lower extremities (to assess for nerve involvement).
Functional assessment: Observe the patient performing basic movements (e.g., squatting, walking on toes) to assess functional limitations (e.g., walking distance, ability to climb stairs).
Imaging Studies (if recent):
X-rays: May be used to rule out fractures or bony abnormalities.
MRI scan: The most detailed imaging for LSS, showing nerve compression by narrowed spinal canal.
Assessment:
Diagnosis: Confirm the diagnosis of lumbar spinal stenosis.
Severity: Briefly describe the perceived severity of stenosis based on symptoms, functional limitations, and imaging findings.
Neurological status: Mention any evidence of nerve compression (e.g., weakness, numbness).
Plan:
Treatment:
Outline the treatment plan based on the severity and individual needs. This may include:
Conservative management:
Activity modification to avoid triggers.
Physical therapy to improve core strength, flexibility, and balance.
Oral medications (e.g., NSAIDs, neuropathic pain medications) for pain management.
Steroid injections (epidural or facet joint) for localized pain relief (limited course).
Consideration for minimally invasive procedures: For patients with moderate LSS and persistent pain despite conservative measures. Examples include: * Facet joint injections with radiofrequency ablation. * Vertebral augmentation (kyphoplasty) for vertebral compression fractures.
Surgical intervention: May be considered for severe LSS with significant pain, progressive neurological deficits, or cauda equina syndrome (severe nerve compression). The type of surgery depends on the specific anatomy and stenosis location.
Weight management: Encourage weight loss if overweight or obese, as it can significantly improve symptoms.
Education:
Educate the patient about LSS, causes, treatment options, and self-care strategies (e.g., proper posture, maintaining a healthy weight).
Follow-up:
Schedule follow-up visits to monitor response to treatment and discuss the need for further intervention based on symptom progression.
Advise the patient to return sooner if symptoms worsen significantly or red flags develop (e.g., severe weakness, bowel/bladder incontinence).