Diagnosis: Lumbar spinal stenosis at L4-L5 and L5-S1.
Secondary diagnosis: Degenerative disc disease at L4-L5.
PMHx: Hypertension, hypercholesterolemia.
Imaging: MRI lumbar spine, 27 October 2024, showing moderate spinal stenosis at L4-L5 and L5-S1 with associated disc bulges.
Plan: Review imaging results and discuss with patient. Consider referral to physiotherapy.
Follow-up in 4 weeks.
BASS booklet links: https://www.nhs.uk/conditions/sciatica/
Mr. John Smith, [age 62], male, presents today for review of lower back pain. He has been seen previously in the clinic for similar complaints, with previous imaging showing mild degenerative changes.
Mr. Smith reports a gradual onset of lower back pain radiating into his left leg, exacerbated by prolonged standing and walking. He describes the pain as a dull ache with intermittent sharp shooting pains. He also reports some numbness in his left foot.
There are no signs of cauda equina syndrome. No lower limb weakness or sensory loss was noted on examination.
The MRI scan of the lumbar spine, performed on 27 October 2024, reveals moderate spinal stenosis at L4-L5 and L5-S1, with associated disc bulges. There is also evidence of degenerative changes at L4-L5.
Management options include conservative measures such as physiotherapy, pain medication (paracetamol, ibuprofen), and lifestyle modifications. Interventional options include epidural steroid injections. Surgical options, such as laminectomy and fusion, are available but are reserved for severe cases.
Patient information leaflets on spinal stenosis and sciatica were provided.
Mr. Smith is keen to avoid surgery if possible. He is willing to try physiotherapy and pain medication initially.
We will review the imaging results and discuss them with the patient. We will also consider a referral to physiotherapy. A follow-up appointment is scheduled for 4 weeks.
Mr. Smith would prefer to try physiotherapy and pain medication as his initial intervention.
If the patient experiences new or worsening symptoms such as bowel or bladder dysfunction, or significant new weakness, they should seek immediate medical attention.
Diagnosis:
[describe the primary diagnosis, including the specific condition and location] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
[describe any secondary diagnoses, including the specific condition and location] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
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PMHx:
[list relevant past medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
Imaging:
[detail any relevant imaging studies, including the type of imaging, the date performed, and the body part imaged] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
Plan:
[describe immediate next steps, such as further imaging or referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
[describe subsequent follow-up plans, such as clinic reviews] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
BASS booklet links:
[provide relevant BASS booklet links] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.)
[provide an introductory summary of the patient, including age, gender, and previous review history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[describe the patient's current symptoms, including location and specific complaints] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[document the absence of specific clinical features, such as cauda equina syndrome or lumbar motor radiculopathy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[interpret findings from recent imaging, specifying relevant anatomical locations and observations such as disc bulges and neural compression] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[outline available management options, categorizing them (e.g., conservative, interventional, surgical) and providing specific examples for each] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[mention any attached resources or links related to the patient's condition for further reading] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[document the patient's preferences or aversions regarding treatment options, particularly concerning surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[detail immediate plans for the patient, such as requesting updated imaging and scheduling subsequent reviews based on results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[state the patient's preferred initial intervention if they decide to pursue further management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[provide critical safety advice regarding emergent symptoms, specifying conditions that require immediate medical review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
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(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
