First Consultation
Date of consultation: 01/11/2024
File Number: 2024-NEURO-007
Patient Name: Ms. Eleanor Vance
Date of birth: 15/03/1972
Age: 52 years
Preferred language: English
Service type: Outpatient Neurosurgery Consultation
Referred by: Dr. Sarah Jenkins (General Practitioner)
Weight: 68 kg
Height: 165 cm
BMI: 24.98
Employment status: Retired Teacher
Medically boarded: Not applicable
Marital status: Married
Smoking status: Non-smoker
Drinking habits: Occasional social drinking (2-3 units per week)
Cancer history: None
Medical conditions:
1. Hypertension (I10)
2. Type 2 Diabetes Mellitus (E11.9)
3. Osteoarthritis, lumbar spine (M47.816)
Chronic medications: Lisinopril 10mg daily, Metformin 500mg twice daily
Pain medications: Ibuprofen 400mg as needed (currently not taking)
Over-the-counter medications: Multivitamin daily
Other pain treatments: Physiotherapy for lumbar pain (completed 3 months ago)
Allergies: Penicillin (T36.0X5A - rash)
Previous operations:
1. Appendectomy (1990) - General Hospital
2. Cholecystectomy (2005) - St. Jude's Hospital
Cardiac risk factors (CHF past 30 days): None
Excessive bleeding risk factors: None
Infection risk factors: Well-controlled diabetes
Renal risk factors: None
Respiratory risk factors: None
VTE risk factors: None
Functional status: Independent with ADLs, mild limitations with prolonged standing/walking due to back pain.
MRI contraindications: None
Injury on duty: No
Medico-legal issues: None
Neurosurgical Consultation Note
Referral Source and Indication:
Ms. Eleanor Vance was referred by Dr. Sarah Jenkins due to persistent and worsening low back pain radiating into her left leg, suggestive of lumbar radiculopathy, despite conservative management.
History of Present Illness:
Patient presents with a 6-month history of progressive low back pain, described as a dull ache, with intermittent sharp, shooting pain radiating down the posterior aspect of her left thigh and calf. The pain is exacerbated by prolonged sitting, standing, and walking, and partially relieved by lying down. She reports occasional numbness and tingling in the left foot. No bowel or bladder incontinence, saddle anaesthesia, or significant motor weakness reported. Symptoms began insidiously after an episode of bending to lift groceries. Has tried over-the-counter pain relievers and a course of physiotherapy with limited long-term success.
Past Medical and Neurosurgical History:
Hypertension, Type 2 Diabetes Mellitus, Osteoarthritis. No prior neurosurgical interventions.
Medication and Allergy History:
Currently taking Lisinopril 10mg daily and Metformin 500mg twice daily. Allergies: Penicillin (rash).
Neurological Examination:
General: Well-appearing, cooperative, in no acute distress. Gait: Antalgic, favouring the left leg. Mild difficulty with heel-to-toe walking. Lower Extremities: Power 5/5 bilaterally in hip flexion, knee extension, dorsiflexion, plantarflexion. Decreased sensation to light touch in the L5 dermatome on the left. Deep tendon reflexes: Patellar 2+ bilaterally, Achilles 1+ on left, 2+ on right. Straight leg raise positive on the left at 45 degrees, negative on the right. Motor: No focal weakness. No fasciculations. Coordination: Intact. Cranial nerves: II-XII intact and symmetrical.
Imaging and Diagnostic Studies:
Lumbar MRI performed on 15/10/2024: Revealed a large L4/L5 disc protrusion with significant compression of the left L5 nerve root. Mild degenerative changes at L5/S1.
Diagnosis or Impression:
Lumbar disc herniation L4/L5 with left L5 radiculopathy (G54.1).
Management Plan:
Discussed surgical and non-surgical options. Patient keen to explore surgical intervention due to persistent symptoms affecting quality of life. Plan includes: 1. Trial of targeted epidural steroid injection. 2. If no significant improvement, microdiscectomy at L4/L5 on the left side.
Complaint:
Chronic low back pain (M54.5) with left L5 radiculopathy (G54.1) for 6 months, impacting daily activities.
Visual Analog Pain Score:
7/10
Oswestry Disability Index:
48% (Severe Disability)
Summary of Complaint:
Ms. Vance describes her pain as a constant low back ache, aggravated by movement, with intermittent sharp, radiating pain down her left leg to the foot. She experiences numbness and tingling in her left foot, impacting her ability to walk and stand for extended periods.
Examination:
Revealed an antalgic gait, positive left straight leg raise, diminished left Achilles reflex, and sensory deficit in the left L5 dermatome. Remaining neurological examination was unremarkable.
Radiological Examinations:
Lumbar spine MRI (15/10/2024) demonstrates a large left-sided L4/L5 disc protrusion causing significant compression of the left L5 nerve root.
Treatment Plan:
1. Lumbar epidural steroid injection (ESI) at L4/L5. (ICD-10-PCS: 027U3ZZ – Injection into spinal canal, lumbar). Risks discussed include infection, bleeding, temporary pain flare, nerve damage (rare).
2. If ESI fails to provide lasting relief, surgical microdiscectomy at L4/L5 (ICD-10-PCS: 0SB03ZZ – Excision of vertebral disc, lumbar, open approach). Risks discussed include infection, bleeding, dural tear, nerve damage, recurrence of herniation, failed back surgery syndrome.
Surgical consent:
Risks and benefits of microdiscectomy thoroughly discussed with Ms. Vance. She understands the potential complications including infection, bleeding, CSF leak, nerve injury, and the possibility of persistent pain or recurrence. Patient is agreeable to proceed if conservative measures fail.
Follow up:
Review in 4-6 weeks post-ESI or sooner if symptoms worsen. If ESI is unsuccessful, discuss scheduling for microdiscectomy.
First Consultation
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Medical conditions:
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Previous operations:
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Neurosurgical Consultation Note
Referral Source and Indication:
[Record referral source and clinical reason for neurosurgical assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of Present Illness:
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Past Medical and Neurosurgical History:
[Record comorbidities and previous neurological history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medication and Allergy History:
[Insert current medications and allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological Examination:
[Document neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Imaging and Diagnostic Studies:
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Diagnosis or Impression:
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Management Plan:
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Complaint:
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Visual Analog Pain Score:
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Oswestry Disability Index:
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Summary of Complaint:
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Examination:
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Radiological Examinations:
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Treatment Plan:
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Surgical consent:
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Follow up:
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(For each section, only include if explicitly mentioned in the transcript or contextual notes; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, examination findings, assessments, plans, interventions, investigations, consent details, or follow-up. Use only the transcript, contextual notes, or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Add ICD-10 codes only when explicitly provided in the source material.)
