ENFORCE28129 - Laserfiche WebLink

Home Browse Search

'i ' DURANGO ORTHOPEDIC AS50CIATES, P.C. ^RTNOPEDIC SURGERY ~ Bpp CAST THIPp AV EHU C. 4UIT[ 16 DURANG ^, COLORADO 61301 tCICFHpNE: 3p]-Z a9~536] TAx Lp. Np. 01-(1500567 wIL LiAM J. KRAUSE P. w.p. DEAR L. IU AO V. x,. p. 9APRY HILLMEA. M.p. L08AT0, Fidel Ref: Leo W. Lloyd, M.D. 12-13-82 HISTORY: This 60-year-old male was referred to us by Dr. t;;l Lloyd for evaluation of low back pain and left leg pain. Apparently this i:' gentleman operates a small coal mine all by himself but about one week `~r ago fie noticed spon is neuu, arlS e2 v` ~Gr Uc:. ~: -y3 i.: `.':i tfi r?'~i ?tin inta the left leg. This came on actually after a shopping trip where he was standing for prolonged periods of time. Since then he has been unable to work and has remained fairly quiet at home and he thinks perhaps the back is slightly better, but he is still getting much pain in the leg with some numbness and a feeling of weakness. He did have some back trouble about two years ago and at that point was told that he miight have a slipped disk, but after being sent to the VA hospital in Grand Junction, they told him there wis nothing wrong with him and he did eventually clear up without t-eatment and has been rela- tively free of pain up until the present time. He feels his general health is good. He denies any serious past history and takes no med- ications on a regular basis except occasional aspirin. EXAMINATION: Today reveals a healthy appearing 60-year-old male who stands erect. He does have tenderness over the lumbosacral interspace in the midline and left sciatic notch. Range of back mo- tion, though, is fairly good. He can almost touch the toes with the _ fingertips on forward flexion.. Heel and toe gait are performed with- ' out much difficulty. DTRs reveal brisk and normal right knee and ankle reflexes. On the left there is an absent knee reflex but a normal ankle reflex. There is positive SLR on the left at about 65 or 70 degrees whereas he can SLR on the right to almost 90 degrees without pain. Abdominal exam is negative for masses or tenderness. X-rays of the LS spine obtained in the office today do show marked narrowing of L4-5 witYi hypertrophic spur formation around this involved joint. There are some other minor arthritic changes in the lumbar segments but nothing too serious and L5-S1 spate is quit.F well maintained. IMPRESSION: Probable herniated intervertebral disk, L4-5, with lumbar spondylosis RECOMMENDATIONS: Patient will be treated on a conservative basis at home with bed rest, heat to the low back, muscle relaxants (Maolate), and F",otrin , 400 ma, qi.d. We'll see how he progresses over the next week and if fie doesnt sea¢~~significantly improved, .then we might wish to admit him to the haspital for more intensive PT. .,. ----~ cc: Dr. Lloyd Dean L. FuPry, M.D.J