From the Guidelines
The patient is a 45-year-old female presenting for follow-up regarding chronic back pain and leg weakness, and her history of present illness should be rewritten to improve clarity, structure, and readability while maintaining medical accuracy. To achieve this, the following key points should be considered:
- Maintain a clear chronological order of symptoms
- Use professional and clinical language while keeping it easy to read
- Remove any physical exam findings or treatment plans
- Keep the OLDCARTS format in mind to ensure completeness Some possible questions to ask to complete this history include:
- Initial onset of back pain
- Pain severity on a scale of 1-10
- Specific activities that worsen or improve symptoms
- Radiation patterns of pain As noted in the guidelines for diagnosis and treatment of low back pain by the American College of Physicians and the American Pain Society 1, a practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement. The patient's symptoms, including intermittent sharp pains in the posterior aspect of her legs and associated weakness after prolonged standing, as well as numbness in her legs after sitting for extended periods, should be thoroughly evaluated in the context of her occupation and medical history, as suggested by the guidelines 1. A comprehensive and well-structured history of present illness is essential for guiding subsequent decision-making and ensuring the best possible outcomes for the patient.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
History of Present Illness (HPI) Rewrite
To improve clarity, structure, and readability while maintaining conciseness and medical accuracy, the HPI can be rewritten as follows:
- The patient is a 45-year-old female presenting for a follow-up visit to discuss her ongoing back pain and leg weakness.
- The onset of her symptoms began after working at Sonic for 19 years, standing on concrete, which she believes contributes to her symptoms.
- The location of her pain is primarily in the back of her legs, on the right side, with associated weakness when standing for long periods.
- The duration of her symptoms is ongoing, with no reported history of falls or injuries to her legs.
- The characteristics of her pain include short pains in the back of her legs and weakness.
- Aggravating factors include standing for long periods, while relieving factors are not clearly identified.
- The timing of her symptoms is constant, with no reported fluctuation.
- The severity of her symptoms is significant, impacting her daily activities.
Additional Details for Completeness
To ensure completeness, possible questions to ask the patient include:
- Can you describe the exact location and radiation of your leg pain?
- How long have you been experiencing numbness in your legs after sitting for extended periods?
- Have you noticed any factors that relieve or exacerbate your symptoms?
- Can you rate the severity of your pain on a scale of 1-10?
Relevant Studies
Studies such as 2, 3, and 4 provide guidance on the evaluation and management of chronic low back pain, including the importance of identifying red flags and yellow flags, and the use of nonpharmacologic and pharmacologic interventions. Additionally, studies 5 and 6 discuss the efficacy and tolerability of methocarbamol in treating low back pain, which is relevant to the patient's medication history.