AI Scribe for Pain Medicine Specialists
Focus on treating pain, not charting. Medwriter understands pain management nuances.
Medwriter AI Session
Dr: Okay Mrs. Jones, tell me how your low back pain has been since the epidural injection last month.
Patient: It was definitely better for about two weeks, maybe 60% improvement. But the pain started creeping back over the last week or so. The sharp pain down my leg isn't as bad though.
Dr: So about two weeks of significant relief from the injection. Are you still taking the gabapentin regularly?
Patient: Yes, three times a day. It helps take the edge off the nerve pain, but the aching in my back is still bothersome, maybe a 6/10 today.
Dr: Have you been able to do more activity or physical therapy?
Patient: A little bit more walking when it felt better, but I haven't gone back to PT yet.
Dr: Alright. Let's re-examine your back today and discuss the next steps.
🗣️SUBJECTIVE:
- Patient is a 55 y/o female with chronic low back pain and left sciatica (L5 radiculopathy) s/p L4-5 lumbar epidural steroid injection (LESI) 1 month ago.
- Reports ~60% pain relief for approx. 2 weeks following LESI, with significant reduction in left leg radicular pain.
- Over the past week, reports gradual return of axial low back pain, described as aching, currently 6/10 NPRS.
- Left leg pain remains improved compared to pre-injection baseline, currently 3/10.
- Continues Gabapentin 300mg TID with partial benefit for neuropathic symptoms.
- Denies new numbness, weakness, bowel/bladder changes.
- Functionally, reports slight increase in walking tolerance during period of pain relief, but activity limited again currently.
- ORT score reviewed, remains low risk.
👀OBJECTIVE:
- Vitals: Stable.
- Exam: LSpine: Mild tenderness to palpation L4-5 paraspinals. ROM: Flexion limited to 60 deg by pain, extension limited to 10 deg. SLR positive on left at 45 deg reproducing back/leg pain (previously 30 deg). Strength 5/5 BLES. Sensation intact BLES. Reflexes 2+ patellar, 1+ Achilles bilaterally.
- UDS: Consistent with prescribed medications.
📋ASSESSMENT:
- Chronic Low Back Pain (M54.5)
- Lumbar Radiculopathy, Left (L5 distribution) (M54.16): Improved but persistent following LESI.
- Status Post L4-5 LESI: Provided moderate temporary relief.
📝PLAN:
- 1. Discussed partial/temporary response to LESI. Options reviewed include repeat LESI vs. trial of different intervention (e.g., facet joint evaluation if indicated) vs. focus on non-interventional management.
- 2. Medication Management: Continue Gabapentin 300mg TID. Discussed adding topical analgesic (e.g., Lidocaine patch) - patient amenable. Avoided opioid escalation.
- 3. Referrals: Re-referral to Physical Therapy for core strengthening and stabilization program.
- 4. Procedures: Plan for repeat L4-5 LESI in 4-6 weeks if symptoms warrant and patient desires. Discussed risks/benefits.
- 5. Patient Education: Importance of PT adherence, activity pacing.
- 6. Follow-up: RTC in 4 weeks to reassess symptoms and decide on repeat injection.
- 99214 - E/M code appropriate for visit complexity, data review, and medical decision making.
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