Chest Pain Intake

Subjective:
Chief Complaint:
Severe worsening back pain, numbness, difficulty walking, considering spine surgery

History of Present Illness:
The patient presents with severe worsening back pain, numbness in hands and feet, and difficulty walking, ongoing since at least February. The patient has a congenital skin condition (uromethymorosis) with cysts on the spine and was scheduled for spine surgery in February but declined due to concerns about surgical risks. Since then, the patient reports progressive worsening of pain, frequent falls, inability to walk without falling, and increasing numbness. The pain is described as severe, constant, and interfering with sleep. The patient states, "I can't live with this pain no more," and "I don't care if I live or die. I just can't live with this pain no more." The patient has been taking pregabalin, naproxen, and baclofen at higher than prescribed doses without relief, and occasionally uses Tylenol 3 and Advil from others, which provide some relief. The patient is unable to work due to pain and reports difficulty with daily activities. The patient expresses regret about declining surgery and is now considering proceeding with it.

Past Medical History:
Congenital skin condition (uromethymorosis) with cysts on the spine. No history of coronary artery disease or previous myocardial infarction.

Family History:
No significant family history of cardiac diseases.

Social History:
Works in construction but not working currently due to pain. Reports difficulty with daily activities. Patient does not have money to buy over-the-counter melatonin.

Current Medications:
Pregabalin 75 mg, patient reports taking up to 5 at once (exceeds prescribed dose). Naproxen, instructed 2/day, patient reports taking up to 5 at once. Baclofen, instructed 2/day, patient reports taking up to 5 at once. Occasionally uses Tylenol 3 and Advil from others for pain relief. Patient is not taking Tylenol regularly. Patient is not taking melatonin for sleep. Patient is not allowed to get Tylenol 3's. Patient is not taking any other medications besides those listed. Patient does not have any more repeats of pain medication. Patient is not taking any antipsychotic or antidepressant medications.

Allergies:
No known drug allergies.

Past Surgical History:
Pt did not undergo planned spine surgery in Feb. No other surgical hx provided.

The Review of Systems:
Psych: expresses severe distress due to pain, reports inability to sleep, states pain is unbearable, expresses regret about declining surgery, fears surgical risks, reports inability to work or perform daily activities. Musculoskeletal: reports inability to walk without falling, difficulty ambulating, unable to carry objects. Neurological: reports numbness in hands and feet. GI: denies use of Tylenol except occasional Tylenol 3 from uncle, occasional Advil from friends. Medications: reports taking pregabalin, naproxen, baclofen at higher than prescribed doses without relief.

Objective:
Physical Examination:
General Appearance: Patient appears moderately anxious.
Cardiovascular Examination: Heart sounds are normal without murmurs, rubs, or gallops. Pulse is regular and symmetrical.
Respiratory Examination: Lung fields are clear to auscultation; no wheezes, rales, or rhonchi.
Gastrointestinal Examination: Abdomen is soft and non-tender in the epigastric region.

Assessment:
Problem:
Severe worsening back pain with numbness and gait disturbance, likely secondary to congenital spinal cysts (ICD-9: 724.3).

Differential Diagnosis:
Spinal cord compression: Due to progressive numbness, falls, and severe pain.
Radiculopathy: Given numbness in hands and feet, and pain distribution.
Medication overuse/ineffectiveness: Due to high-dose use and lack of relief.

Plan:
Medications: Maximize current prescribed doses of pregabalin, naproxen, and baclofen. Add stomach protection due to high NSAID use.
Further Testing: No additional tests ordered at this visit.
Patient Education: Discussed risks and benefits of surgery, medication safety, and avoidance of medication overuse. Advised to follow up with spine specialist as scheduled.
Follow-up: Return to clinic or ER if symptoms worsen, new neurological deficits, or inability to ambulate.