Letter to referring doctor

Subjective: Patient presents with a chief complaint of chronic lower back pain, radiating into the left leg. The pain is described as a constant, dull ache with occasional sharp, shooting pains. The patient reports that the pain is exacerbated by prolonged sitting and standing, and is partially relieved by rest and over-the-counter pain medication. Objective: * Tenderness to palpation in the lumbar region, particularly at the L4-L5 level. * Positive straight leg raise test on the left side at 45 degrees. * Reduced range of motion in the lumbar spine. Imaging: * MRI of the lumbar spine reveals a moderate-sized disc herniation at the L4-L5 level, impinging on the left L5 nerve root. Plan: We discussed the patient's current pain management strategies and the limitations of these approaches. I have recommended a course of physical therapy to improve core strength and flexibility. I have also prescribed a short course of oral steroids to reduce inflammation. We will schedule a follow-up appointment in four weeks to assess the patient's response to treatment and discuss further options, including possible interventional procedures if conservative measures are unsuccessful. Instructions given: The patient was advised to avoid activities that exacerbate their pain, including heavy lifting and prolonged sitting. They were instructed on proper posture and body mechanics. They were also provided with information on the potential side effects of the prescribed medications. Explanations regarding pain management: The patient was educated on the importance of a multimodal approach to pain management, including physical therapy, medication, and lifestyle modifications. We discussed the potential benefits and risks of each treatment option. Warnings regarding medications, alcohol, driving, or complications of procedures: The patient was warned about the potential side effects of the prescribed medications, including drowsiness and gastrointestinal upset. They were advised to avoid alcohol while taking the medication and to refrain from driving or operating heavy machinery until they know how the medication affects them. Thank you for your kind referral. Please do not hesitate to reach out if there are any questions.