Clinic letter
Date: 1 November 2024
Dr. Sarah Jones
General Practitioner
Acorn Medical Practice
123 High Street, Anytown, AB1 2CD
Dear Dr. Jones:
Re: John Smith, DOB: 12/03/1970
Thank you for referring this patient who I reviewed on 28 October 2024
History of Presenting Complaint:
Mr. Smith presented with a three-month history of worsening lower back pain. The pain is described as a dull ache, radiating down his left leg. It is exacerbated by prolonged sitting and standing, and relieved by rest. There is no history of trauma. He reports some associated numbness and tingling in his left foot.
Past Medical History:
Hypertension, diagnosed in 2018, managed with medication.
Medications:
Lisinopril 10mg once daily.
Allergies:
No known allergies.
Family History:
Father had a history of heart disease.
Social History:
Mr. Smith is a retired accountant. He is a non-smoker and drinks alcohol occasionally. He lives with his wife.
Physical Examination:
Observation: Mr. Smith walks with a slight limp.
Spine: Tenderness to palpation over the L4-L5 region. Reduced range of motion in lumbar flexion.
Neurological: Reduced sensation to light touch in the L5 dermatome. Straight leg raise test positive at 45 degrees on the left.
Investigations:
Lumbar spine X-ray performed, showing mild degenerative changes.
Impression:
Suspected lumbar radiculopathy secondary to degenerative changes.
Plan:
- Advised to continue with over-the-counter pain relief (paracetamol and ibuprofen).
- Physiotherapy referral to commence next week.
- Review in 4 weeks to assess progress.
I will review the patient again on 26 November 2024
Kind regards,
Dr. Emily Carter
General Practitioner
Oakwood Medical Centre
456 Oak Avenue, Anytown, CD3 4EF
Clinic letter
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