Chief Complaint:

• The patient is experiencing severe lower back pain radiating down both legs, accompanied by numbness in her feet.

History of Present Illness (HPI):

• The patient presented to my office three months ago with complaints of progressively worsening lower back pain.
• She reports that the pain radiates bilaterally down her lower extremities and is associated with persistent numbness in both feet.
• The pain has been constant for the past two months and is significantly exacerbated by prolonged periods of sitting or standing. It has become so severe that it is severely limiting her daily activities, including mobility and basic tasks, and is also interrupting her sleep.
• Despite her efforts to manage the pain with over-the-counter NSAIDs (Aleve), she reports minimal relief. The lack of effective pain control is contributing to a decline in her overall quality of life.
• The patient also reports additional symptoms, including dizziness, generalized weakness, and chronic fatigue, which have been occurring concurrently with the back pain.
• She denies any history of recent injury, falls, or trauma that could account for the onset of her symptoms.

Past Medical History:

• The patient has a history of gastroesophageal reflux disease (GERD), which she manages with a daily dose of Protonix (pantoprazole).
• Approximately two years ago, she experienced a similar episode of back pain, which at that time responded well to conservative treatment, including physical therapy and pain management.

Clinical Findings:

• Physical examination findings are consistent with degenerative lumbar spinal stenosis. There is also a concern for possible cervical myelopathy, given the presence of neurological symptoms such as numbness, dizziness, and weakness.
• Preliminary imaging, including an MRI of the lumbar spine, reveals signs of degenerative changes that may be contributing to the spinal stenosis. However, further detailed evaluation is required to assess the extent of cervical involvement.

Reason for Referral:

• Given the chronic and debilitating nature of her symptoms, alongside the preliminary findings suggestive of spinal stenosis with possible cervical myelopathy, I am referring this patient to you for a comprehensive evaluation.
• We are seeking your expertise in determining the extent of her spinal pathology and to discuss potential surgical or non-surgical treatment options that could alleviate her symptoms and improve her quality of life.

Request for Next Steps:

• Please advise on any additional diagnostic tests or imaging that you would recommend prior to her consultation.
• I would appreciate your assessment of whether surgical intervention is warranted or if there are alternative therapies that should be considered.