Date: 1 November 2024
Patient: John Smith
File: JS-2024-001
Outpatient Neurosurgical Follow-up Note
Visit Context:
Postoperative review following lumbar microdiscectomy for L4-L5 disc herniation. Patient is 6 weeks post-surgery.
Symptoms and Patient Concerns:
Patient reports significant improvement in left leg radicular pain. Pre-operative VAS score of 8/10 has reduced to 2/10. Occasional mild back stiffness noted, but no significant back pain. No numbness, weakness, seizures, gait disturbance, or cognitive changes.
Neurological Examination:
Cranial nerves intact. Motor examination reveals 5/5 strength in all extremities. Sensory examination shows no deficits to light touch or pinprick. Coordination intact. Reflexes 2+ bilaterally at knees and ankles. Gait is steady and unassisted.
Wound and Recovery Status:
Surgical site healing well, clean and dry with minimal scarring. No signs of infection. Patient is ambulating independently and has returned to light activities of daily living. Reports gradual increase in functional capacity.
Imaging and Investigations Reviewed:
Lumbar spine MRI performed 5 weeks post-op reviewed. Shows successful decompression at L4-L5 level with no residual disc herniation or significant canal stenosis. No concerning changes or recurrence.
Device or Implant Review:
N/A (No implanted devices for this procedure).
Complications or Adverse Events:
No delayed complications such as hydrocephalus, hematoma, seizure activity, or neurological deterioration observed or reported.
Plan and Follow-up:
Continue with current physical therapy regimen. Patient advised to gradually increase activity levels as tolerated. Prescribed PRN analgesia for occasional back stiffness. Follow-up in 3 months with repeat MRI if symptoms recur or worsen. Discharge from neurosurgical care if remains asymptomatic at next follow-up.
Date: [Insert date of examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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Outpatient Neurosurgical Follow-up Note
Visit Context:
[Record reason for follow-up such as postoperative review, imaging assessment, symptom recurrence, or second opinion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention surgery performed, date of surgery, and days post surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Symptoms and Patient Concerns:
[Document presence or resolution of neurological symptoms including headache, pain, weakness, numbness, seizures, gait disturbance, or cognitive changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention pain score (e.g. VAS score out of 10) and presence of back or leg pain] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological Examination:
[Describe findings from cranial nerves, motor examination, sensory examination, coordination, reflexes, and gait] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Wound and Recovery Status:
[Comment on surgical site healing, signs of infection, scar formation, and functional recovery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Imaging and Investigations Reviewed:
[Summarize findings from post-operative or surveillance CT, MRI, or angiograms including any concerning changes or recurrence] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Device or Implant Review:
[Document review of implanted devices such as shunts, stimulators, hardware integrity, or related complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Complications or Adverse Events:
[Note any delayed complications such as hydrocephalus, hematoma, seizure activity, or neurological deterioration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan and Follow-up:
[Outline next imaging, referrals, multidisciplinary input, medication changes, additional surgical planning, or discharge from neurosurgical care] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(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, examination findings, assessments, plans, interventions, investigations, or follow-up. Use only the transcript, contextual notes, or clinical note as the source of information. If any information related to a placeholder has not been explicitly mentioned, do not state that it is absent—simply omit the placeholder or section entirely. Use as many lines or paragraphs as needed to accurately capture the documented information.)