Pain Clinic Note

Date of clinic: 01/11/2024 Patient particulars: Sarah Jenkins (15/03/1978) NHS No. 987 654 3210 Hospital No. SJ7890123 Address: 123 Elm Street, Anytown, AB1 2CD Insurer: Bupa Letter to Dr. Eleanor Vance Copy to Dr. Marcus Chen (GP), Ms. Emily White (Physiotherapist) Dear Dr. Vance I reviewed Sarah in my clinic today for a follow-up consultation. Review: Sarah Jenkins, a 46-year-old female, presented for a follow-up regarding her chronic lower back pain, which has been ongoing for approximately 5 years. She was initially referred by her GP, Dr. Chen, due to persistent pain despite conservative management including physiotherapy and oral analgesics. Her primary complaint remains a dull, aching pain in her lumbar spine, radiating occasionally down her left leg to the knee, consistent with a radicular pattern. She describes the pain as 6/10 at its worst, often exacerbated by prolonged sitting or standing, and partially relieved by rest and heat packs. Since her last review three months ago, she reports a slight improvement in her pain intensity and frequency, attributing this to adherence to her prescribed duloxetine and regular home exercises. She expresses ongoing concerns about the impact of the pain on her work as an accountant and her ability to engage in recreational activities with her children. Shared decision-making focused on exploring further interventional options and reinforcing the importance of continued exercise and pain coping strategies. I explained the potential benefits and risks of a lumbar epidural steroid injection. Her past medical history includes essential hypertension, well-controlled with ramipril, and no significant surgical history relevant to her pain. She lives with her husband and two children, and works full-time. She denies smoking and drinks alcohol occasionally. Examination: On observation, Ms. Jenkins exhibited a comfortable posture without obvious antalgic gait. Vital signs were stable: BP 130/80 mmHg, HR 72 bpm, RR 16 bpm. Palpation revealed mild tenderness over the L4-L5 paraspinal muscles. Lumbar spine range of motion was mildly restricted in flexion and extension, but rotation and lateral flexion were within normal limits. Neurological examination of the lower extremities showed intact motor power (5/5) in bilateral hip flexion, knee extension, ankle dorsiflexion, and plantarflexion. Sensation to light touch was intact in L2-S1 dermatomes. Deep tendon reflexes (patellar and Achilles) were 2+ bilaterally. Straight leg raise test was positive on the left at 70 degrees, reproducing her typical leg pain. Summary: - 46-year-old female with chronic lower back pain and left leg radiculopathy for 5 years, partially improved with duloxetine and exercise. - Mild tenderness in L4-L5 paraspinal region and mildly restricted lumbar flexion/extension. - Left-sided straight leg raise positive at 70 degrees; otherwise, neurological exam is unremarkable. - Clinical impression is chronic lumbar radiculopathy, likely secondary to discogenic pathology at L4/L5, with an improving trend but ongoing functional impact. - Currently on duloxetine 60mg daily, paracetamol PRN; no medication-related issues reported. - No relevant surgical history. - MRI lumbar spine from 6 months ago showed L4/L5 disc bulge with mild left-sided neural foraminal narrowing. The patient's presentation is consistent with chronic lumbar radiculopathy, with an ongoing neuropathic component. Diagnosis: 1. Chronic Lumbar Radiculopathy (Left L5) 2. Lumbar Disc Degeneration L4/L5 3. Essential Hypertension Management Plan: 1. Discussed and consented for a left-sided L5 transforaminal epidural steroid injection. Patient understands potential risks and benefits. 2. Continue current duloxetine 60mg daily. Review efficacy in 6 weeks post-injection. 3. Refer back to physiotherapy for targeted core strengthening and mobility exercises post-injection. 4. Advised on pacing activities and applying heat/ice as needed for symptom flares. 5. Follow-up appointment scheduled for 8 weeks to assess injection efficacy and overall pain management. Many thanks Yours sincerely Dr. Thomas Kelly (Consultant in Pain Management) Consultant in Pain Management Tasks: For Admin Team: - Book left-sided L5 transforaminal epidural steroid injection for Ms. Jenkins. - Send referral to physiotherapy for post-injection rehabilitation. - Schedule follow-up appointment for 8 weeks. - Distribute letter to Dr. Eleanor Vance, Dr. Marcus Chen, and Ms. Emily White. For Self: - Review pre-procedure imaging before injection. - Prepare patient information leaflet for epidural injection. Other Tasks: - None.