HPI: Mr. G is a 35-year old established patient of our clinic who was admitted as an inpatient two days ago by Orthopaedics

    May 5, 2024

HPI: Mr. G is a 35-year old established patient of our clinic who was admitted as an inpatient two days ago by Orthopaedics following a very severe MVA. He, unfortunately, suffered multiple fractures during the accident and was taken to the OR yesterday for operative repair. Currently he is being maintained in traction due to the multiple fractures of his left leg. Mr. G is followed in our clinic for low back pain due to lumbar radiculopathy and lumbar degenerative disc disease. Due to having to lie in bed, his back pain has been increased and I was asked to see him for management of his back pain. EXAM: General: BP: 118/76 Respiration: 20 Heart Rate: 72 Afebrile. Patient is alert and oriented x 3. Currently he is lying in a hospital bed. He appears pale and distressed, with significant bruising on his arms. States that he feels very lucky that it was not worse. States that because he cannot move around, he feels a lot of pressure on his low back with increased pain measuring 8/10 on VAS scale. States that all things considered, his current injuries are not that bothersome when compared to his back. ASSESSMENT: Lumbar DDD

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