Neurosurgeon First Consultation
Date of consultation: 01/11/2024
File Number: P1234567
Patient Name: Sarah Johnson
Date of birth: 15/03/1985
Age: 39
Preferred language: English
Service type: Neurosurgical Consultation
Referred by: Dr. Emily White, GP
Weight: 70 kg
Height: 165 cm
BMI: 25.7
Employment status: Employed, Marketing Manager
Medically boarded: No
Marital status: Married
Smoking status: Ex-smoker (5 pack years)
Drinking habits: Social drinker, occasional glass of wine (2-3 units/week)
Cancer history: None
Medical conditions:
1. Hypertension (I10)
2. Type 2 Diabetes Mellitus (E11.9)
Chronic medications:
1. Lisinopril 10mg daily
2. Metformin 500mg twice daily
Pain medications:
1. Paracetamol 500mg as needed
Over-the-counter medications:
1. Multivitamin daily
Other pain treatments: Physiotherapy for lower back pain, massage therapy
Allergies: Penicillin (hives)
Previous operations:
1. Appendectomy (2005)
2. C-section (2012)
Cardiac risk factors (CHF during past 30 days): NONE
Excessive bleeding risk factors: None
Infection risk factors: None
Renal risk factors: None
Respiratory risk factors: None
VTE risk factors: None
Functional status: Partially independent (limited by back pain)
MRI contraindications: None
Injury on duty: No
Medico-legal issues: No
Referral Source and Indication:
Referred by Dr. Emily White for evaluation of chronic lower back pain with radiating symptoms suggestive of lumbar disc herniation.
History of Present Illness:
Ms. Johnson presents with a 6-month history of persistent lower back pain radiating down her left leg to the foot. The pain started insidiously without a specific injury and has gradually worsened. It is described as a sharp, shooting pain exacerbated by prolonged sitting, standing, and bending. She reports numbness and tingling in the left foot, particularly in the big toe. She has tried conservative management including physiotherapy, pain medication, and rest, with limited relief. The pain interferes with her daily activities and work.
Past Medical and Neurosurgical History:
* Hypertension, controlled with Lisinopril.
* Type 2 Diabetes Mellitus, managed with Metformin.
* No previous neurological diagnoses or neurosurgical procedures.
Medication and Allergy History:
* Current medications: Lisinopril 10mg daily, Metformin 500mg twice daily, Paracetamol 500mg as needed.
* Allergies: Penicillin (hives).
Neurological Examination:
* Gait: Antalgic, leaning to the right.
* Motor: Left foot dorsiflexion 4/5, left great toe extension 4/5. Other lower limb strength 5/5 bilaterally. Upper limb strength 5/5 bilaterally.
* Sensory: Diminished sensation to light touch in left L5/S1 dermatomes.
* Reflexes: Left ankle jerk 1+, right ankle jerk 2+. Knee jerks 2+ bilaterally.
* Straight Leg Raise: Positive on the left at 45 degrees.
Imaging and Diagnostic Studies:
* Lumbar Spine MRI (dated 20/10/2024): Revealed a large left-sided L5/S1 disc extrusion compressing the left S1 nerve root.
Diagnosis or Impression:
* Left L5/S1 disc extrusion with S1 radiculopathy (M51.26)
Management Plan:
* Discussed surgical options including microdiscectomy.
* Explained risks and benefits of surgery vs continued conservative management.
* Recommend further conservative management for 4-6 weeks with epidural steroid injection trial.
* If conservative management fails, consider surgical intervention.
* Referral to Pain Management Specialist for epidural steroid injection.
* Follow-up in 6 weeks to reassess symptoms and discuss surgical planning if needed.
Complaint:
Ms. Sarah Johnson, a 39-year-old female, presents with a 6-month history of debilitating left-sided lower back pain radiating into her left leg and foot. The pain is described as sharp and shooting, rated 7/10 on the Visual Analog Scale, and is associated with numbness and tingling in the left big toe. Her symptoms are consistent with lumbar radiculopathy secondary to disc pathology (M51.26).
Visual Analog Pain Score:
7/10
Oswestry Disability Index:
32/50 (64%)
Summary of Complaint:
The patient's pain is primarily localised to the left lumbar region, radiating down the posterior aspect of the left thigh and calf, into the left foot, specifically affecting the dorsum of the foot and the great toe, indicative of L5/S1 dermatomal distribution. Myotomal weakness is observed in the left foot dorsiflexors and great toe extensors.
Examination:
* General: Alert and oriented, appears to be in mild distress due to pain.
* Spinal: Tenderness to palpation over L5/S1 spinous processes. Reduced lumbar flexion and extension due to pain. Paravertebral muscle spasm noted on the left.
* Cranial Nerves: Intact.
* Motor: Left foot dorsiflexion 4/5, left great toe extension 4/5. Remainder of motor examination 5/5.
* Sensory: Hypoesthesia to light touch in left L5 and S1 dermatomes.
* Reflexes: Left ankle jerk 1+, right ankle jerk 2+. Knee jerks 2+ bilaterally.
* Special Tests: Positive left straight leg raise at 45 degrees. Negative contralateral straight leg raise.
Radiological Examinations:
* Lumbar Spine X-rays (previous, not reviewed today): Unremarkable.
* Lumbar Spine MRI (20/10/2024): Large left paracentral L5/S1 disc extrusion with significant compression of the left S1 nerve root. No significant spinal stenosis at other levels.
Treatment Plan:
* Diagnosis: Left L5/S1 disc extrusion with S1 radiculopathy (M51.26).
* Conservative management: Continue with physiotherapy, consider a caudal epidural steroid injection.
* Surgical options: Left L5/S1 microdiscectomy was discussed as a definitive treatment if conservative measures fail. Expected outcomes include significant pain reduction and resolution of neurological deficits, though no guarantees can be made.
* Patient expectations: Wishes for complete resolution of pain and return to previous activity levels.
* Clinician expectations: Realistic improvement in pain and function, potential for residual numbness or weakness post-surgery.
Surgical Consent:
* Discussed potential complications of microdiscectomy:
* General surgical risks: Infection (2-5%), bleeding (1-3%), anaesthetic risks.
* Specific neurological risks: Nerve root injury (0.1-0.5%) leading to increased weakness or numbness, dural tear (1-5%) potentially requiring further surgery, recurrent disc herniation (5-10%).
Follow up:
* Re-evaluation in 6 weeks following epidural steroid injection or sooner if symptoms worsen significantly.
"First Consultation"
Date of consultation: [Date of the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use DD/MM/YYYY format.)
File Number: [Patient file number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Patient Name: [Full name of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Date of birth: [Patient date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use DD/MM/YYYY format.)
Age: [Patient age in years] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Preferred language: [Patient's preferred language] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Service type: [Type of service] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Referred by: [Source of referral] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Weight: [Patient weight] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Record in kg.)
Height: [Patient height] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Record in cm.)
BMI: [Patient BMI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If both weight in kg and height in cm are documented, calculate BMI using the formula: weight (kg) divided by height (m) squared, and round to one decimal place.)
Employment status: [Patient employment status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Medically boarded: [Whether the patient is medically boarded and the date this occurred] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Marital status: [Patient marital status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Smoking status: [Patient smoking status and calculated pack year history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Non-smoker". If smoking status is mentioned, calculate pack years by multiplying the number of packs smoked per day by the number of years smoked and include in brackets.)
Drinking habits: [Patient alcohol consumption habits] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Cancer history: [Patient history of cancer] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Medical conditions: [All medical conditions documented for the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. List each condition numerically and include the relevant ICD-10 code in brackets after each condition.)
Chronic medications: [Chronic medications the patient is taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Pain medications: [Pain medications the patient is taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Over-the-counter medications: [Over-the-counter medications the patient is taking] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Other pain treatments: [Other pain treatments the patient is receiving or has received] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Allergies: [Patient allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Previous operations: [Previous surgical procedures the patient has undergone] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. List each procedure numerically.)
Cardiac risk factors (CHF during past 30 days): [Cardiac risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NONE".)
Excessive bleeding risk factors: [Excessive bleeding risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "None".)
Infection risk factors: [Infection risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "None".)
Renal risk factors: [Renal risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "None".)
Respiratory risk factors: [Respiratory risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "None".)
VTE risk factors: [Venous thromboembolism risk factors relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "None".)
Functional status: [Patient functional status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Independent".)
MRI contraindications: [MRI contraindications relevant to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Injury on duty: [Whether the presenting problem is related to an injury on duty] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "No".)
Medico-legal issues: [Whether any legal steps are being considered in relation to the patient's condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "No".)
Referral Source and Indication:
[Referring clinician or service and the clinical reason for the neurosurgical assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
History of Present Illness:
[Onset, duration, progression and nature of the patient's presenting symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Past Medical and Neurosurgical History:
[Relevant past medical conditions, previous neurological diagnoses and prior neurosurgical procedures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Medication and Allergy History:
[Current medications and known allergies relevant to the neurosurgical assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Neurological Examination:
[Findings from the neurological examination performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Imaging and Diagnostic Studies:
[Results of imaging and diagnostic investigations relevant to the neurosurgical assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Diagnosis or Impression:
[Document the clinician's explicitly stated working diagnosis or differential diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a list.)
Management Plan:
[Further investigations, surgical recommendations, conservative management options and referrals to other services as discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Complaint:
[History of the presenting complaint and reason for the visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Include the relevant ICD-10 code in brackets after each diagnosis mentioned. Write in paragraphs of full sentences.)
Visual Analog Pain Score:
[Patient's pain score out of 10 on the Visual Analog Scale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Oswestry Disability Index:
[Patient's Oswestry Disability Index score and percentage] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Record the score out of 50 and convert to a percentage. If separate neck and back scores are documented, record each separately.)
Summary of Complaint:
[Summary of the patient's pain complaint including possible dermatomal and myotomal distribution] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Examination:
[Findings from the clinical examination performed, including cranial and spinal examination findings where applicable, and both positive and negative findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Radiological Examinations:
[Type and results of radiological investigations performed or reviewed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
Treatment Plan:
[Details of the treatment plan as discussed with the patient, including relevant diagnoses, surgical options where applicable, expected outcomes and patient and clinician expectations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Include the relevant ICD-10 code in brackets after each diagnosis mentioned. If surgery was discussed, include common complications as discussed. Write as a list.)
Surgical Consent:
[Details of the surgical consent discussion, including complications discussed and their associated percentages] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. List each complication with its percentage.)
Follow up:
[Planned follow-up consultations or investigations prior to surgery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
