First consultation Dr Steyn

Neurosurgeon First Consultation Date of consultation: 01/11/2024 File Number: P1234567 Patient Name: Sarah Johnson Date of birth: 15/03/1985 Age: 39 Preferred language: English Service type: Neurosurgical Consultation Referred by: Dr. Emily White, GP Weight: 70 kg Height: 165 cm BMI: 25.7 Employment status: Employed, Marketing Manager Medically boarded: No Marital status: Married Smoking status: Ex-smoker (5 pack years) Drinking habits: Social drinker, occasional glass of wine (2-3 units/week) Cancer history: None Medical conditions: 1. Hypertension (I10) 2. Type 2 Diabetes Mellitus (E11.9) Chronic medications: 1. Lisinopril 10mg daily 2. Metformin 500mg twice daily Pain medications: 1. Paracetamol 500mg as needed Over-the-counter medications: 1. Multivitamin daily Other pain treatments: Physiotherapy for lower back pain, massage therapy Allergies: Penicillin (hives) Previous operations: 1. Appendectomy (2005) 2. C-section (2012) Cardiac risk factors (CHF during past 30 days): NONE Excessive bleeding risk factors: None Infection risk factors: None Renal risk factors: None Respiratory risk factors: None VTE risk factors: None Functional status: Partially independent (limited by back pain) MRI contraindications: None Injury on duty: No Medico-legal issues: No Referral Source and Indication: Referred by Dr. Emily White for evaluation of chronic lower back pain with radiating symptoms suggestive of lumbar disc herniation. History of Present Illness: Ms. Johnson presents with a 6-month history of persistent lower back pain radiating down her left leg to the foot. The pain started insidiously without a specific injury and has gradually worsened. It is described as a sharp, shooting pain exacerbated by prolonged sitting, standing, and bending. She reports numbness and tingling in the left foot, particularly in the big toe. She has tried conservative management including physiotherapy, pain medication, and rest, with limited relief. The pain interferes with her daily activities and work. Past Medical and Neurosurgical History: * Hypertension, controlled with Lisinopril. * Type 2 Diabetes Mellitus, managed with Metformin. * No previous neurological diagnoses or neurosurgical procedures. Medication and Allergy History: * Current medications: Lisinopril 10mg daily, Metformin 500mg twice daily, Paracetamol 500mg as needed. * Allergies: Penicillin (hives). Neurological Examination: * Gait: Antalgic, leaning to the right. * Motor: Left foot dorsiflexion 4/5, left great toe extension 4/5. Other lower limb strength 5/5 bilaterally. Upper limb strength 5/5 bilaterally. * Sensory: Diminished sensation to light touch in left L5/S1 dermatomes. * Reflexes: Left ankle jerk 1+, right ankle jerk 2+. Knee jerks 2+ bilaterally. * Straight Leg Raise: Positive on the left at 45 degrees. Imaging and Diagnostic Studies: * Lumbar Spine MRI (dated 20/10/2024): Revealed a large left-sided L5/S1 disc extrusion compressing the left S1 nerve root. Diagnosis or Impression: * Left L5/S1 disc extrusion with S1 radiculopathy (M51.26) Management Plan: * Discussed surgical options including microdiscectomy. * Explained risks and benefits of surgery vs continued conservative management. * Recommend further conservative management for 4-6 weeks with epidural steroid injection trial. * If conservative management fails, consider surgical intervention. * Referral to Pain Management Specialist for epidural steroid injection. * Follow-up in 6 weeks to reassess symptoms and discuss surgical planning if needed. Complaint: Ms. Sarah Johnson, a 39-year-old female, presents with a 6-month history of debilitating left-sided lower back pain radiating into her left leg and foot. The pain is described as sharp and shooting, rated 7/10 on the Visual Analog Scale, and is associated with numbness and tingling in the left big toe. Her symptoms are consistent with lumbar radiculopathy secondary to disc pathology (M51.26). Visual Analog Pain Score: 7/10 Oswestry Disability Index: 32/50 (64%) Summary of Complaint: The patient's pain is primarily localised to the left lumbar region, radiating down the posterior aspect of the left thigh and calf, into the left foot, specifically affecting the dorsum of the foot and the great toe, indicative of L5/S1 dermatomal distribution. Myotomal weakness is observed in the left foot dorsiflexors and great toe extensors. Examination: * General: Alert and oriented, appears to be in mild distress due to pain. * Spinal: Tenderness to palpation over L5/S1 spinous processes. Reduced lumbar flexion and extension due to pain. Paravertebral muscle spasm noted on the left. * Cranial Nerves: Intact. * Motor: Left foot dorsiflexion 4/5, left great toe extension 4/5. Remainder of motor examination 5/5. * Sensory: Hypoesthesia to light touch in left L5 and S1 dermatomes. * Reflexes: Left ankle jerk 1+, right ankle jerk 2+. Knee jerks 2+ bilaterally. * Special Tests: Positive left straight leg raise at 45 degrees. Negative contralateral straight leg raise. Radiological Examinations: * Lumbar Spine X-rays (previous, not reviewed today): Unremarkable. * Lumbar Spine MRI (20/10/2024): Large left paracentral L5/S1 disc extrusion with significant compression of the left S1 nerve root. No significant spinal stenosis at other levels. Treatment Plan: * Diagnosis: Left L5/S1 disc extrusion with S1 radiculopathy (M51.26). * Conservative management: Continue with physiotherapy, consider a caudal epidural steroid injection. * Surgical options: Left L5/S1 microdiscectomy was discussed as a definitive treatment if conservative measures fail. Expected outcomes include significant pain reduction and resolution of neurological deficits, though no guarantees can be made. * Patient expectations: Wishes for complete resolution of pain and return to previous activity levels. * Clinician expectations: Realistic improvement in pain and function, potential for residual numbness or weakness post-surgery. Surgical Consent: * Discussed potential complications of microdiscectomy: * General surgical risks: Infection (2-5%), bleeding (1-3%), anaesthetic risks. * Specific neurological risks: Nerve root injury (0.1-0.5%) leading to increased weakness or numbness, dural tear (1-5%) potentially requiring further surgery, recurrent disc herniation (5-10%). Follow up: * Re-evaluation in 6 weeks following epidural steroid injection or sooner if symptoms worsen significantly.