Primary Care Provider
Low back pain, pain running down leg, sciatica
Strength of Evidence
Date Last Reviewed
Human Factors Engineering (HFE), Office of Health Informatics, Veterans Health Administration
Perform searches within the EHR to gather necessary information to assess and treat the patient.
Patient Dan comes in to see his primary care provider (PCP), with the chief complaint of “low back pain”. Dan rates his pain as a 12/10 to the nurse. This provider just started seeing Dan as his PCP about 6 months ago, so they are only a slightly familiar with him. The PCP briefly reviews Dan’s chart in the electronic health record (EHR) before he comes into the exam room and sees that “chronic low back pain” is listed in his active problem list and that the only active medications in his orders are Naproxen and vitamin D .
As the PCP greets Dan when he enters the room, it is obvious that he is in pain. He has a hard time settling back into his chair and his face is strained. Dan tells the PCP that his back has been bothering him off and on for years, but this time is the worst. He relates that he moved a couch around his daughter’s apartment for her about one month ago, and while doing this, felt a pop in his back then noticed severe pain in his right low back radiating down to his right foot with numbness in the right leg. He denies any bowel or bladder incontinence or numbness in his perineal area . He has been trying to wait this out at home with using only his Naproxen, but it isn’t getting better.
The PCP asks him when his last MRI of his low back was done so he can review the results, and Dan states “I don’t know, I had it at my old VA before I moved here.” The PCP performs a chart search for the results of Dan’s last MRI of the lumbar spine.
Unfortunately, the MRI report that is in the EHR reads: “see VistA Imaging for scanned report”. The electronic report is only as a placeholder because the MRI was done through ‘non-VA care’. The PCP has to review Dan’s VistA Imaging records to see the scanned image of the actual report that was received by fax. The PCP finds the report, and notes that Dan had a bulging disk on the right side at L5/S1 three years ago.
The PCP asks Dan how his back pain was treated three years ago when he had the MRI. Dan relates that he had some kind of procedure at his old VA, but is not sure if it was an ablation or an epidural injection . He does say that at the time, it seemed to significantly relieve his pain. The PCP performs a chart search to determine what kind of procedure Dan had.
The PCP sees in the pain consult that Dan was complaining of pain down his right leg back then as well. Dan relates that yes, he remembers this, and says he even did some kind of “nerve study” back then through a non-VA neurologist. The PCP performs a chart search for an electromyogram (EMG) study by entering in “EMG”.
The PCP finds a placeholder in the EHR for the EMG that reads: “see VistA Imaging for scanned report” because it was completed through ‘non-VA care’. The PCP has to review Dan’s Vista Imaging records to see the scanned image for the actual report and find that results were consistent with sciatica at the time.
The PCP examines Dan and informs him that they suspect he is having a flare of his sciatica similar to what he experienced three years ago and are hopeful that another series of epidural injections will relieve his pain again. The PCP orders an updated MRI of his lumbar spine and places a consult to the interventional pain service, however the PCP knows that these may takes weeks to complete and Dan will need his pain controlled in the interim.
The PCP asks Dan what medications have helped relieve his pain in the past. Dan relates that prednisone did not help him and that he forgets what else he has had. He just knows that “that one med” made him really dizzy and he never wants that again. The PCP reviews Dan’s allergies/adverse drug reactions (ADR) to search for any medications that may have caused dizziness and unfortunately his only listed ADR is ‘shellfish’. The PCP performs a chart search for a medication that caused dizziness.
The search returns a note that states Gabapentin was discontinued because the patient experienced dizziness. The PCP adds Gabapentin to Dan’s ADR list.
The PCP asks Dan how much Naproxen he is currently taking for his pain since that is what is on his medication list. Dan relates that he was taking the maximum dose and it wasn’t working. He had some left over old pain medications in his cabinet and had been taking those but he ran out. He doesn’t remember if they were Vicodin or Percocet , but they really helped. He asks the PCP to prescribe them again and to only give him a limited number because he “doesn’t want to get hooked on them”. The PCP performs a search for what medications have been dispensed in the past.
The PCP finds that 30 Percocet tablets were dispensed three years ago from Dan’s previous VA. The PCP performs a search to find out whether or not substance abuse has ever been an issue for Dan. 
The PCP finds appropriate urine drug screens in the past, no problem list entries for substance abuse, and no substance abuse referrals. The PCP also finds no reference to substance abuse in Dan’s previous pain consult notes.
The PCP informs Dan they will prescribe 30 Percocet tablets, order an X-ray of his lower back, followed by an MRI of his lower back (for which he will be contacted for scheduling by radiology), and recommends a home exercise physical therapy (PT) program to help relieve his pain the in the interim. Dan says he has home exercises from prior PT sessions, but would like to have a formal course of PT again because they do other interventions like ultrasound that he can’t do at home and they really helped. The PCP asks Dan if his last formal course of PT for back pain was within the last six months, because the medical center does not allow new PT referrals for same problems if the patient was seen in PT within the 6 months prior. Dan does not remember when his last formal PT order was so the PCP performs a search for the last PT appointment.
The PCP finds that Dan’s last PT appointment was 8 months ago, so they place a new PT consult for Dan. Dan thanks his PCP for their help. He leaves to go to radiology to get his X-ray of his lower back done today and stop at the pharmacy after that to pick up his Percocet for his pain.