DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sacroplasty.
HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old woman who, last Friday, developed nausea, vomiting, and diarrhea. She got up multiple times during the night. On two occasions, she thinks she passed out and lost consciousness briefly; once she was in the bathroom. The patient thinks she was out for only a brief period of time but is unsure. The patient’s husband was unable to get to her because of the doors of the bathroom. In any case, the patient got up on her own and went back to bed. Later, she fell in the hall and injured her right ankle. The patient developed excruciating pain over her tailbone during the course of that night at some point and at about noon, the following day, came to the hospital. The patient still complains of severe pain over the midline tailbone. This is not exacerbated particularly by weightbearing but is by direct pressure, either being supine or sitting. The patient is unable to do these things. The pain is in the tip of her back and does not radiate to her legs. The patient denies new lower extremity weakness or numbness or changes in bowel or bladder habits over the last several days since she hurt her back. The patient has no history of cancer, stroke or GI bleeding.
PAST MEDICAL HISTORY: Significant for hypertension and osteoporosis. Other history includes dyslipidemia, glucose intolerance, trigeminal neuralgia, and CDT colitis.
PAST SURGICAL HISTORY: She has had internal fixation of the left knee fracture, right foot surgery, D&C, hysterectomy, tonsillectomy, and adenoidectomy.
ALLERGIES: THE PATIENT IS INTOLERANT OF INDOCIN.
MEDICATIONS: The patient’s medications presently include Topamax, aspirin, gemfibrozil, Lipitor, Lidoderm, lidocaine patch, Lovenox, and ketoprofen.
PHYSICAL EXAMINATION: The patient is very pleasant and cooperative, in no acute distress. She is exquisitely point tender over the tailbone, in the midline, in a very small localized area. The patient has symmetric 4+/5 strength on lower extremities, including hip flexion and plantar/dorsiflexion of both ankles. Light touch sensation is decreased over both feet but symmetrically; she states this is old and relates it to poor circulation. Light touch sensation is symmetric and normal in the calves and thighs. The patient has well heel-to-shin testing bilaterally. She has swelling around the right ankle and dorsum of the right foot, and there is ecchymosis around the right ankle.
IMPRESSION AND PLAN: We reviewed her MRI sacrum. This demonstrates transverse fracture of the sacrum at the S3-4 level. There is minimal, if any, involvement at the anterior aspects of the ala, perhaps inferiorly so, on the right. There was also an adjacent nerve root sleeve diverticulum on the right side. There was thick rind of enhancement around this. While unlikely, certainly the imaging characteristics could be compatible with infection. Certainly, this is most likely to be traumatic-related inflammation. We spoke with her about cement fixation of the sacral fracture for relief of her pain. On the other hand, since she is ambulatory, we told her we thought conservative therapy, at least for a trial of that, would be reasonable prior to intervening. We talked about the risk and benefits of percutaneous cement fixation of her fracture. The patient understands and indicates she would like to proceed with conservative therapy for the time being. We will ask the office to call her next week to see how she is doing.
