November who came to my office seeking Chiropractic care

November
28, 2017

Dr. L. B.

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Pain

2065 Finch
Avenue West

Suite 123

North York,
Ontario

M3N 2V7

 

Dear Dr. L.

B. Pain:

 

RE: Mr. Wendel Blark

Date Of Birth: September 24, 1994

Clinic Note

 

 

BACKGROUND

 

Thank you
for seeing my 23-year-old patient, Wendel Blark. Wendel is a plumber who came
to my office seeking Chiropractic care after he began experiencing lower back
pain during a camping trip. The onset of his pain was insidious, and it has
been identified as a lumbar disc herniation at L4/L5 coupled with an L5
radiculopathy. He is an otherwise healthy individual with no pertinent prior
injuries or trauma with which to attribute this pain, which makes him a
candidate for surgical intervention. The patient’s goal of treatment is to be
able to return to his physically demanding job as soon as possible.

 

5 weeks ago
Wendel came to my office with a chief complaint of deep, “lightning bolt” or
“knife-like” pain down the posterior surface of his right thigh during the
swing phase of gait. He described the pain as constant, and when asked to show
the location of pain he pointed to the gluteal and hamstring region of the
posterior thigh, the lateral leg, as well as numbness in the region of the 2nd
toe and the web of the toe. Upon description of the pain, he defined his back
pain as “bruise-like” and duller than that in his posterior thigh and leg. The
patient’s pain is worsened by straightening his back, sneezing and going to the
bathroom. Pain is also replicated by prolonged sitting. The pain is relieved by
laying supine with support under his knees. After chiropractic care for the
past 5 weeks, his pain has decreased from a 10/10 to a 5/10.

 

PHYSICAL EXAMINATION

 

During my
postural examination, I noted that he had a reduced lumbar lordosis when
viewing laterally as well as slight flexion in his right hip and knee allowing
for less pressure to be placed on the right foot. Upon anterior-posterior
examination, he presented with an antalgic list to the left side, away from the
site of the lesion.

 

He did not
place as much weight on his right heel during the gait examination. Wendel also
experienced pain and weakness on his right side when walking on his heels. The
patient was able to walk on his toes without issue, but struggled with
dorsiflexion during heel-walking.

 

The patient
had decreased trunk flexion by a margin of 75% and a 50% decrease in extension.

Right-sided lateral flexion presented pain in the right popliteal fossa,
left-sided flexion created a slight pulling sensation in the right buttock,
this pain was also reproduced by trunk rotation to the right. Kemp’s test was
also positive on the right side. Achilles reflex testing yielded a 2+ rating
and was unremarkable.

 

Sensory
testing revealed hypesthesia in the L5 dermatome on the right leg and had
weakened great toe extension, with the right extensor hallucis longus having
weakness on a scale of 4 out of 5. Dermatomal testing for L4 and S1 was
unremarkable. Supporting the diagnosis of a disc herniation, the Valsalva
manoeuvre was positive. In addition, Pheasant’s test and crossed-legged
straight leg raise was positive on the right with pain felt at 45 degrees of
flexion down the posterior thigh.

 

CLINICAL DIAGNOSIS

 

Lumbar disc
herniation at the L4/L5 level with right lumbar radiculopathy (herniation on
the right side).

 

RECOMMENDATIONS

 

I recommend
that the patient continues with chiropractic care, including soft tissue work
and mobilizations, as this has relieved the pain over the past 5 weeks.

However, I also recommend that Mr. Blark receives an MRI to confirm the
diagnosis and possible surgical intervention so he may return to work. Due to
the physicality of his job, I believe chiropractic care alone may not be enough
for Wendel to return to work and, as such, may require surgery to relieve the
pain associated with the condition.

 

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: General Practioner

      
Mr. Wendel Blark

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