GP Medical Update

Date: 1 November 2024 Dear Dr Smith, Re: John Doe Date of Birth: 15 May 1970 (54 years old) File: JD/NS/2024/001 Thank you for the referral of Mr John Doe, who presented with progressive lower limb weakness. I saw John Doe on the 1 November 2024 regarding his complaints of progressive weakness and numbness in both lower limbs, which began approximately six months ago. The symptoms are worse after prolonged standing and are partially relieved by rest. He reports difficulty climbing stairs and occasional stumbling. He has tried over-the-counter pain relievers and physiotherapy without significant improvement. He has no prior history of similar neurological deficits. Medical Conditions: * Hypertension, well-controlled * Type 2 Diabetes Mellitus, well-controlled Surgical History: * Appendectomy, 1985 Medication Used: * Ramipril 5mg daily * Metformin 1000mg twice daily Social History: Smokes 5 cigarettes per day for 20 years, consumes alcohol socially (2-3 units per week). Allergy: * Penicillin (hives) Clinical examination that was performed on 1 November 2024 showed reduced power (4/5) in both tibialis anterior and gastrocnemius muscles, diminished sensation to light touch and pinprick in a L4/L5 distribution bilaterally. Deep tendon reflexes were brisk in the patella and Achilles bilaterally. There was no clonus. Gait was antalgic with a mild foot drop on the right. Radiological investigations performed included a lumbar spine MRI conducted on 25 October 2024, which revealed significant L4/L5 disc herniation causing severe central canal stenosis and impingement of the bilateral L5 nerve roots. The diagnosis of severe lumbar spinal stenosis at L4/L5 due to disc herniation was made, and surgical decompression options, including laminectomy and discectomy, were discussed in detail with the patient. Non-surgical management, including epidural injections and further physiotherapy, was also presented, along with their respective success rates and potential risks. The decision was made to proceed with surgical decompression at the L4/L5 level due to the progressive nature of his symptoms and the significant radiological findings. The patient has been scheduled for pre-operative assessment and has consented to the procedure. If you have any enquiries, please feel free to contact us. Once again thank you for the referral. Kind regards Dr. Thomas Kelly Neurosurgeon MBBS, FRCS (Neuro.Surg) Medical Practice Number: 1234567 Practice Registration Number: NS78901