December it as an 8/10, with no actions able

December 13,
2017

Dr. L. B.

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Pain

2065 Finch
Avenue West, Suite 123

North York,
Ontario

M3N 2V7

 

RE: Mr. E. Scott

Date Of Birth: September 24, 1944

Clinic Note

 

Dear Dr. L.

B. Pain:

 

I am
referring my patient, Mr. E. Scott, to you as a general practitioner for
further evaluation. He is a 73-year-old, retired male who came into my office
with the chief complaint of insidious-onset low back pain, and I feel there may
be something further to explore.

 

The patient’s
low back pain began insidiously 4 months ago and has only gotten worse since
its onset. It is a dull, achy pain in the lumbar and gluteal regions with no
signs of a radiculopathy. At its worst, he considers the pain extremely intense
and rates it as an 8/10, with no actions able to alleviate the symptoms.

Flexion and prolonged sitting makes the pain considerably worse.

 

This pain
is concerning to me because Mr. Scott has a previous history of prostate
cancer, for which he has been in remission for 6 years. He also has associated
symptoms of constipation, intense night pain and unexplained weight loss, which
he attributed to the back pain. His last oncologist appointment was 6 months
ago, however, all of these symptoms have arisen since that date.

 

I would
like your professional opinion on his condition before I continue with
treatment for this patient, as I would like to rule out cancer or any other
serious condition before I begin with my physical examination and plan of
management.

 

Thank you
again for seeing this patient for me, and if you have any questions do not
hesitate to contact my office.

 

Yours
sincerely,

 

 

 

Dr. Ashley Stenzel (Student Number: 118708),
Hons. BSc.Kin, DC

 

Cc: Mr. E. Scott

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