Spinal Elective OP - First Visit

[describe the patient's presenting issues, including the nature of their balance problems, the characteristics of their lumbar claudication, the spinal levels affected by stenosis, and any previous surgical history related to spinal decompression] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document the patient's personal details, including their age, occupation, and previous medical history, such as prior surgeries and any pre-existing conditions that have been assessed and optimized] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [detail any current medications, including antihypertensives, hypercholesterol tablets, and any blood-thinning medications, as well as the patient's recovery status from previous surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the patient's understanding of the proposed treatment plan and their consent to proceed with any operations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [document findings from the physical examination, including assessment of balance (static and dynamic Romberg's), location and nature of pain (e.g., buttock pain, absence of trochanteric or groin elements), and the presence of nerve root tension signs] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [detail neurological examination findings, including upper limb reflexes, clumsiness, Hoffmann's sign, lower limb characteristics (e.g., dilated veins, sensations, numbness, tingling), pulses, and muscle power for hip flexors, knee extensors, ankle/foot dorsiflexors, and plantar flexors. Also, note any long tract signs and Babinski reflex findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [summarize the findings from reviewed scans, specifically mentioning the severity of stenosis at relevant spinal levels and the status of any previously decompressed areas] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [outline the rationale for requesting further urgent imaging, such as a whole spine MR, and the specific concerns it aims to investigate, like cord compression or tandem stenosis. Also, state if the scan has been ordered] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [detail the immediate plan for patient review, including the timeline for the review and the intended procedure to be consented for, such as a right-sided L4/5 decompression, based on updated scan results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (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.)