Bradford VTS GP Concise Consult

HISTORY - reports LBP 6wks, dull ache radiating L leg - 6wks duration, worse prolonged sitting/standing, relieved by rest, no trauma - OTC paracetamol gives partial relief, tried heat pack – no benefit - gradually worsening since onset - similar episode 2y ago, settled with physio - limits ability to walk >30 mins, avoids lifting - reports numbness L foot, denies SOB, CP, fever PMH - PMH: HTN dx 2018, on lisinopril - SH: retired accountant, non-smoker, occasional ETOH, lives w/ wife - FH: father – IHD - Exposure: nil relevant - Immunisations: UTD - Other: nil EXAMINATION - obs stable: HR 72, BP 134/82, afebrile - gait: mild limp L - spine: tender L4-L5, ↓ROM lumbar flex - neuro: ↓LT sensation L5 dermatome, SLR +ve @45° L - blds: normal - XR lumbar: mild degen changes IMPRESSION 1. L radiculopathy 2° degen disc disease 2. chronic LBP 3. DDx: disc herniation, spinal stenosis PLAN 1. LBP/radiculopathy - DDx: disc herniation, spinal stenosis - planned: MRI lumbar spine - to continue OTC analgesia (paracetamol + ibuprofen) - referral: physio (starts next wk) 2. HTN - to continue lisinopril 10mg OD - no new concerns, BP within target