Complete Shadow Health Pain Assessment for Edward Carter. Chronic lower back pain rated 10/10 with left L4-L5 radiculopathy, history of opioid use disorder, comprehensive PQRSTU pain evaluation, functional impact assessment, psychosocial screening and physical examination.
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Edward Carter presents with chronic lower back pain radiating into the left leg following an L4-L5 dermatomal distribution. He rates pain at 7/10 at rest, rising to 10/10 on arrival. Pain is described as sharp and burning, worsened by prolonged standing and relieved by lying down. He has a documented history of opioid use disorder and is currently managed under a pain contract.
The Pain Assessment covers a comprehensive PQRSTU pain evaluation, functional impact on activities of daily living, psychosocial screening including depression and social isolation secondary to chronic pain, substance use history, and complete musculoskeletal and neurological examination.
Positive straight leg raise on the left at 40°. Decreased sensation L4-L5 dermatome. Strength 4/5 left lower extremity. Diagnosis: Chronic low back pain with left L4-L5 radiculopathy.