Patient name and hospital number:
John Smith, 1234567
Letter to:
Dr. Jane Doe, GP
Cc to:
Dr. Robert Jones, Consultant Anaesthetist
PLEASE ENSURE THE QR CODE LINK IS ON THE BOTTOM
Reason for Attendance
New patient assessment for chronic lower back pain.
Diagnosis
Chronic lower back pain, lumbar facet joint arthropathy.
Current Medication
* Paracetamol 1g four times daily
* Ibuprofen 400mg three times daily
* Amitriptyline 10mg at night
Previously trialled Medication
* Codeine - caused constipation and nausea.
Action for GP
Continue current medication regime. Consider referral to pain psychologist if mood deteriorates.
Assessment
"Thank you for referring John Smith to the Pain Centre. They were seen in a Physiotherapy-led new patient clinic."
Patient presents with chronic lower back pain, radiating to the left leg, exacerbated by prolonged sitting and standing. Pain is described as a constant ache with intermittent sharp shooting pains. The patient reports that the pain has been present for 6 months and has been worsening over the last month.
Patient understands the importance of a multidisciplinary approach to pain management, including physiotherapy, medication, and lifestyle modifications.
Patient lives with his wife and has two adult children. He is retired and enjoys gardening.
Patient worked as a carpenter for 30 years. He reports that his back pain started after lifting a heavy object at work.
Pain significantly impacts sleep, with difficulty falling asleep and frequent awakenings due to pain.
Patient reports mild low mood and some anxiety related to the pain and its impact on his activities. No previous history of mental health issues.
Patient understands that his pain is likely multifactorial and that there is no quick fix.
Patient expects to gain a better understanding of his pain and to develop strategies to manage it more effectively.
Patient is motivated to improve his function and quality of life.
Goal areas for rehabilitation include improving pain levels, increasing mobility, and returning to gardening.
Examination
General examination findings: Well-appearing, comfortable at rest.
Physical examination findings for pain assessment and neurological/musculoskeletal systems: Tenderness to palpation over the lumbar facet joints. Reduced lumbar range of motion. Positive straight leg raise test on the left. Neurological examination intact.
Discussion with Patient
Discussed the nature of chronic pain and the importance of a biopsychosocial approach. Explained the role of physiotherapy, medication, and lifestyle modifications.
Provided education on pain mechanisms and self-management strategies.
Discussed the benefits of regular exercise, pacing activities, and stress management techniques.
Advised on ergonomic adjustments at home and work.
Management Plan
Continue current medication regime. Commence physiotherapy program. Consider a trial of a TENS machine.
Follow-up
Review in 6 weeks with Physiotherapist and Pain Specialist.
Date: 1 November 2024
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Patient name and hospital number:
[Patient name and hospital number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Letter to:
[Letter recipient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Cc to:
[Cc recipient(s)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PLEASE ENSURE THE QR CODE LINK IS ON THE BOTTOM
Reason for Attendance
[Reason for attendance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis
[Diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Current Medication
[List of analgesic and adjuvant medications, including doses, followed by other medications and supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Previously trialled Medication
[List of previously trialled medications and reasons for discontinuation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Action for GP
[Medication changes or advice] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment
"Thank you for referring [Patient name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) to the Pain Centre. They were seen in a Physiotherapy-led new patient clinic."
[Reason(s) for consultation, including pain presentation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Summary of patient understanding of rehabilitation approach] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Detailed family and social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Environmental and occupational history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Impact of pain on sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Current mood and psychological factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient’s understanding of their pain] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Expectations of appointment and clinic] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Motivation for rehabilitation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Goal areas for rehabilitation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Examination
[General examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical examination findings for pain assessment and neurological/musculoskeletal systems] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Other relevant system findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion with Patient
[Summary of discussion points] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Summary of advice and education given] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Non-pharmacological interventions discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Lifestyle modifications advised] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Management Plan
[Brief summary of medication changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Brief summary of overall plan and onward referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Follow-up
[Follow-up appointments scheduled] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Discharge plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit entirely. Never generate or assume patient details, diagnoses, assessments, plans, interventions, or follow-up. Use only transcript, contextual notes or clinical note as reference. If information is not explicitly mentioned, omit the section without stating that it is missing. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)
