Dear Mrs. Eleanor Vance, ID: EV7890
Thank you for visiting today and for sharing your health and personal information with me. I appreciate your openness and cooperation during our consultation.
I confirm that you consented to Heidi AI transcription during our consultation.
A summary of our discussion has been provided to ensure clarity and understanding of the proposed treatment.
Your recent MRI scans are available for review on the PACS system.
1. Chronic Lumbar Radiculopathy with Functional Impairment
Mrs. Vance presents with a 5-year history of progressively worsening lower back pain radiating down her left leg, consistent with lumbar radiculopathy. The pain significantly impacts her ability to perform daily activities, including walking, standing for extended periods, and sleeping. She has previously undergone extensive physiotherapy, chiropractic adjustments, and oral analgesics, with only temporary and minimal relief from these interventions.
2. Current Symptom Pattern and Quality of Life Impact
Currently, Mrs. Vance experiences a constant dull ache in her lower back, exacerbated by sitting and prolonged standing, with sharp, shooting pain radiating down the posterior aspect of her left thigh and calf. This pain is rated 7/10 at its worst and limits her walking distance to approximately 100 metres before requiring rest. It prevents her from engaging in her regular gardening hobbies and has led to absenteeism from her administrative work.
3. Imaging Findings and Examination Results
Recent lumbar MRI (1 November 2024) reveals a disc protrusion at L4-L5 causing significant compression of the left L5 nerve root. There is also evidence of degenerative changes at L5-S1. Physical examination revealed tenderness to palpation over the left paraspinal muscles at L4-L5. Straight leg raise test was positive at 45 degrees on the left, eliciting her typical radicular pain. Motor strength in the left lower extremity was 5/5 for all major muscle groups, but sensation was diminished in the left L5 dermatome. Deep tendon reflexes were intact and symmetrical.
4. Proposed Therapeutic Intervention and Treatment Plan
Given the persistent radicular symptoms and objective findings, a lumbar epidural steroid injection (LESI) at the L4-L5 level is proposed. This intervention aims to reduce inflammation around the compressed nerve root, thereby alleviating pain and improving functional capacity. We anticipate a significant reduction in radicular pain, potentially allowing for improved mobility and participation in targeted rehabilitation. If the injection provides good, but short-lived, relief, further consideration will be given to repeat injections or surgical evaluation if symptoms remain refractory. Should this intervention fail to provide meaningful improvement, referral to a pain management specialist for alternative modalities will be considered.
5. Risks and Complications
Potential risks and complications associated with a lumbar epidural steroid injection include, but are not limited to, infection, bleeding, headache (dural puncture), temporary numbness or weakness in the legs, allergic reaction to the medications, increased pain, nerve damage, and steroid-related side effects such as elevated blood sugar or fluid retention. There is also a small risk of inadequate pain relief or the need for further interventions.
Patients should not drive for 24 hours following the procedure.
Patients may experience temporary leg weakness or numbness, increasing the risk of falls immediately post-procedure. Assistance with ambulation may be required.
Mrs. Vance confirmed her understanding of the proposed treatment plan, the expected outcomes, and the potential complications. All of her questions were answered to her satisfaction.
Summary
Main symptoms patient has:
* Chronic lower back pain radiating to the left leg
* Numbness in left L5 dermatome
* Limited mobility due to pain
Main symptoms patient wants addressed:
* Alleviation of left leg radicular pain
* Improved ability to walk and stand
* Return to gardening and work without significant pain
Reason for Visit:
* Evaluation and management of persistent left lumbar radiculopathy
* Discussion of interventional pain management options
History of Presenting Illness:
Mrs. Eleanor Vance is a 62-year-old female presenting with a 5-year history of lower back pain, which has progressively worsened over the last 12 months. The pain initiated subtly but has now developed into a constant dull ache in her lumbar spine, with intermittent sharp, shooting pain radiating down her left leg to the foot. The pain is aggravated by prolonged sitting, standing, and bending, and relieved minimally by rest. She denies any bowel or bladder dysfunction, saddle anaesthesia, or progressive motor weakness. She reports difficulty sleeping due to pain and significant interference with her daily activities and work.
Past Medical History:
* Hypertension (controlled with medication)
* Osteoarthritis
* Hyperlipidaemia
Medications:
* Ramipril 5mg daily (oral)
* Atorvastatin 20mg daily (oral)
* Paracetamol 1g as needed (oral)
* Ibuprofen 400mg as needed (oral)
Allergies:
* Penicillin (rash)
* Codeine (nausea)
Social History:
Smoking Status: Never smoked.
Alcohol Consumption: Occasional social drinker, 1-2 units per week.
Occupation: Retired Administrative Assistant (currently on sick leave).
Living Situation: Lives with her husband in a single-story home, good social support.
Family History:
Her mother had a history of degenerative disc disease and underwent spinal fusion surgery at age 70. Her father had hypertension and a myocardial infarction. There is no family history of significant neurological disorders.
Review of Systems:
General: Denies fever, chills, night sweats. Reports mild fatigue due to pain-related sleep disturbance. No recent weight changes.
Cardiovascular: Denies chest pain, palpitations, or oedema.
Respiratory: Denies cough, shortness of breath, or wheezing.
Gastrointestinal: Denies nausea, vomiting, diarrhoea, or constipation.
Musculoskeletal: Positive for lower back pain radiating to the left leg, stiffness in the morning. Denies joint swelling or inflammatory symptoms in other joints.
Neurological: Positive for left leg numbness and tingling. Denies headaches, dizziness, or visual changes.
Endocrine: Denies excessive thirst, urination, or heat/cold intolerance.
Psychological: Reports feeling frustrated and slightly anxious due to persistent pain and its impact on her life. Denies symptoms of major depression or suicidal ideation.
Physical Examination:
General Appearance: Well-nourished, alert, and oriented female. Appears to be in mild distress due to pain. Good hygiene.
Vital Signs: BP 130/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 36.8°C, SpO2 98% on room air.
Cardiovascular Exam: S1/S2 heard, regular rhythm, no murmurs. Peripheral pulses palpable and symmetrical.
Respiratory Exam: Clear breath sounds bilaterally, no adventitious sounds. Symmetrical chest wall movement.
Abdominal Exam: Soft, non-tender, non-distended. Bowel sounds present in all quadrants. No organomegaly.
Musculoskeletal Exam: Lumbar spine: decreased range of motion in flexion and extension due to pain. Tenderness over left paraspinal muscles at L4-L5. Left SLR positive at 45 degrees. Normal strength in bilateral upper extremities. Left lower extremity strength 5/5, right lower extremity strength 5/5. No joint effusions or erythema.
Neurological Exam: Mental status: alert and oriented x3. Cranial nerves: II-XII intact. Motor: good power in all four limbs (5/5). Sensory: diminished light touch sensation in left L5 dermatome. Reflexes: patellar and Achilles reflexes 2+ bilaterally and symmetrical. Normal gait, but guarded with slight antalgic component.
Investigations:
* Lumbar MRI (1 November 2024): Disc protrusion at L4-L5 with left L5 nerve root compression. Degenerative changes at L5-S1.
Assessment:
Mrs. Eleanor Vance is a 62-year-old female presenting with chronic left lumbar radiculopathy secondary to L4-L5 disc protrusion and nerve root compression, as evidenced by clinical presentation and MRI findings. Her symptoms are significantly impacting her quality of life and daily activities. The current presentation warrants an interventional approach to pain management, as conservative treatments have been exhausted with limited success. The working diagnosis is left L5 radiculopathy.
Plan:
Pharmacological Management:
* Continue current medications.
* Consider a short course of oral corticosteroids if severe flare-up post-injection, as discussed.
Non-Pharmacological Management:
* Continue with light stretching and walking as tolerated.
* Commence targeted physiotherapy 2 weeks post-injection to strengthen core muscles and improve flexibility.
Referrals:
* None at this time, pending response to injection.
Follow-up:
* Review in clinic in 4-6 weeks to assess response to LESI and determine further management.
Patient Education/Counselling:
* Provided detailed explanation of lumbar epidural steroid injection, including procedure, expected benefits, and potential risks.
* Discussed post-procedure care and activity restrictions.
* Emphasised importance of continued exercise and physical therapy.
Next Steps:
Information leaflets about the lumbar epidural steroid injection will be provided. The hospital booking team will contact you to arrange the procedure. We will schedule a follow-up appointment in approximately 4-6 weeks to assess your response to the treatment and plan any future management. Please do not hesitate to contact us if your symptoms worsen or you have any concerns.
The messaging system through our online platform is a complimentary service designed to improve communication between visits, but please note it does not fully replace the hospital booking team or urgent communications.
Thank you for placing your trust in our care. Please feel free to reach out with any questions or concerns you may have.
Dr. Alex Carter, FRCS (Neuro.Surg), Consultant Neurosurgeon
Dear [patient's full name and identifier] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[opening statement expressing appreciation for the patient's visit and their willingness to share health and personal information] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
[statement acknowledging the patient's consent for Heidi AI transcription during the consultation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
[statement confirming that a summary of the consultation discussion has been provided to ensure understanding] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
[describe where imaging is available for review and which system it is accessible through] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
1. [heading describing the primary condition with its chronicity and functional impact] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[describe the patient's condition including its progression, impact on daily activities, and previous treatments with their outcomes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
2. [heading describing current symptom pattern and quality of life impact] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[describe the current characteristics and location of the patient's symptoms, how they change with activity, and their impact on quality of life including exercise routines and work] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
3. [heading describing imaging findings and examination results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[summarise the findings from the patient's recent imaging, specifically mentioning any pathology and its progression, and describe the results of the physical examination including specific movements, tests performed, and any relevant findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
4. [heading describing proposed diagnostic or therapeutic intervention and treatment plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[explain the proposed intervention including the specific details, expected outcomes based on symptom relief, potential surgical or alternative considerations if the intervention is effective but short-lived, and the implications if the intervention fails to provide meaningful improvement including alternative referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
5. [heading for risks and complications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
[state all potential risks and complications associated with the procedure including those related to the procedure itself, general complications, allergic reactions, reactions to medications, need for further interventions, and temporary physical impairments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
[state any post-procedure restrictions on driving] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
[state any post-procedure mobility concerns or fall risks] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
[statement confirming the patient's understanding of the proposed treatment plan, expectations, potential complications, and that all questions were answered satisfactorily] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
Summary
[summarise the main symptoms the patient has] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
[summarise the main symptoms the patient wants addressed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Reason for Visit:
[describe the primary reason or reasons for the patient's visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
History of Presenting Illness:
[document the chronology, characteristics, severity, and any associated symptoms related to the patient's current illness or complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Past Medical History:
[list the patient's significant past medical conditions and diagnoses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Medications:
[list all current medications including dosage, frequency, and route, and any over-the-counter supplements or herbal remedies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Allergies:
[list all known allergies to medications, food, or environmental factors, and describe the nature of any reactions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Social History:
Smoking Status: [document the patient's smoking status including type and quantity if applicable] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
Alcohol Consumption: [document the patient's alcohol consumption habits including frequency and quantity] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
Occupation: [document the patient's current occupation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
Living Situation: [document the patient's living arrangements and social support system] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
Family History:
[document any relevant medical conditions present in the patient's family history that may impact their health] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Review of Systems:
General: [document any general symptoms such as fever, weight loss, or fatigue] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Cardiovascular: [document any cardiovascular symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Respiratory: [document any respiratory symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Gastrointestinal: [document any gastrointestinal symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Musculoskeletal: [document any musculoskeletal symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Neurological: [document any neurological symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Endocrine: [document any endocrine symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Psychological: [document any psychological symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list of positive and negative findings.)
Physical Examination:
General Appearance: [document the patient's overall general appearance including signs of distress, nutritional status, and hygiene] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Vital Signs: [document the patient's vital signs including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise list of values with units.)
Cardiovascular Exam: [document findings from the cardiovascular examination including heart sounds, murmurs, and peripheral pulses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Respiratory Exam: [document findings from the respiratory examination including breath sounds, respiratory effort, and chest wall movement] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Abdominal Exam: [document findings from the abdominal examination including palpation, auscultation, and percussion] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Musculoskeletal Exam: [document findings from the musculoskeletal examination including range of motion, strength, and presence of tenderness or swelling] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Neurological Exam: [document findings from the neurological examination including mental status, cranial nerves, motor, sensory, and reflexes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a concise description.)
Investigations:
[list any ordered or reviewed diagnostic tests, imaging, or laboratory results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list including type of investigation and key findings.)
Assessment:
[provide a concise summary of the patient's main problems, differential diagnoses, and the working diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraphs of full sentences.)
Plan:
Pharmacological Management: [list any prescribed medications including dosage, frequency, and duration, and rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Non-Pharmacological Management: [describe any non-pharmacological interventions such as lifestyle modifications, physical therapy, or counselling] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Referrals: [list any referrals to specialists or other healthcare professionals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Follow-up: [describe the follow-up plan including when and how the patient should be seen again] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Patient Education/Counselling: [document any education or counselling provided to the patient regarding their condition, treatment, or self-care] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief bulleted list.)
Next Steps:
[provide instructions on accessing information leaflets, requesting procedure bookings, and arrangements for follow-up appointments to assess treatment response and determine future management] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
[statement acknowledging the messaging system through the online platform as complimentary and designed to improve communication whilst clarifying it does not fully replace hospital booking team and communications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single sentence.)
[closing statement expressing gratitude for the patient's trust and inviting them to reach out with any questions or concerns] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as a single paragraph of full sentences.)
[clinician's name, credentials, and title] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
