Good morning, Sergeant Smith. How are you doing today?
Morning, doc. My back's been killing me. It's been about three months now. Started during a ruck march at Bragg and it just hasn't gotten better.
Tell me more about the pain. Where exactly is it, and does it go anywhere?
It's right here in my lower back, and it shoots down my left leg. Sometimes all the way to my foot. It gets worse when I sit for a long time or try to lift anything heavy.
On a scale of 1 to 10, what's your pain level right now?
Right now it's about a 6. But on bad days it's an 8 or 9. I had to stop PT completely.
I reviewed your MRI from last month. It shows an L4-L5 disc herniation with some nerve root impingement on the left side, which explains the leg symptoms. Let me do a quick exam.
Straight leg raise is positive on the left at about 40 degrees. Decreased sensation in the L5 dermatome. Reflexes are slightly diminished on the left. Motor strength is 4 out of 5 in the left tibialis anterior.
Alright, here's my assessment. You have chronic lumbar radiculopathy from that L4-L5 disc herniation. I'm going to continue your physical therapy, add gabapentin 300 milligrams three times daily for the nerve pain, and refer you to orthopedic surgery for a consult.