READ THE CASE NOTES AND COMPLETE THE WRITING TASK BELOW.

Patient Name: Alex David a 45-year-old man who is a regular patient at your medical centre.

D.O.B: 15/5/1972

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Patient History:

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 Employed as builder

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 Presents occasionally with lower back pain – clears up with anti-inflammatory medication

 Spinal X-ray 1 year ago – showed narrowing of L4-5 and signs of osteoarthritis in L5-S1

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 Has NIDDM, controlled by diet and exercise

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12/2/2018

 Sudden onset lower back pain yesterday while working, worse than usual

 Worse L side radiating down back of L thigh

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 Took Nurofen, which settled pain but worse this morning, couldn’t go to work

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 Puts hand on L hip when walking, walks slowly

 Tender around lower spine and spinal muscles

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 SLR positive on L side at 45 degrees

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 Leg power and reflexes normal

 Pain inhibiting lumbar flexibility and extension

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Assessment:

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Possible disc prolapse or nerve root irritation from facet joint

Treatment:

 Bed rest 2 days

 Paracetamol and anti-inflammatory 50 mg 2 x daily with food

 Hot water bottle on back, return in 2 days

14/2/2018

 No change in pain in back or leg pain

 neurological examination done – normal

 In pain but says it’s no worse than before, still some difficulty with movement, L side SLR 40-45
degrees

Assessment:

No improvement of symptoms but not worsening

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Treatment:

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Continue as before

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

 NSAIDS increased to 3 x daily

Return in 2 days for review

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

16/2/2018

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 No change in back pain

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 Radiating leg pain worse, more constant, especially at night

 Urine test showed glycosuria 2+ (usually none)

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 Obviously in pain, difficulty in movement, walks slowly, still tender and with decreased motion, SLR
30 degrees L.side

 Random blood glucose taken 10 mmol

Assessment:

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Inactivity making diabetes symptoms worse.

Treatment:

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 Continue treatment as before review in 5 days

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 Paracetamol/codeine 30 mg x 6 hourly

 Reason for diabetes symptoms worsening explained – diet modification recommended because of
inactivity

19/2/2018

 Called urgently to patient’s home

 Pain increased overnight in back and down. L. leg, pain not controlled by any medication, Lower L
leg has become numb

 Pain caused inability to get out of bed

 SLR 10 degrees L leg and 30-40 degrees R. Leg, also no ankle flexion, decreased pin prick sensation
in areas

 Random blood glucose increased to 14 mmol

Assessment:

Condition not relieved by medication, signs indicate nerve root compression and disc prolapse

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Treatment:

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Ambulance transport to Royal Melbourne Hospital Emergency Department arranged, phoned

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orthopedic registrar and arranged for hospitalization and orthopedic assessment

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Writing Task:

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Using the information in the case notes, write a letter of referral to Dr. Matthew Sebastian, Royal
Melbourne Hospital, Melbourne 3054.

In your answer:

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 Expand the relevant notes into complete sentences

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 Do not use note form

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 Use letter format

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The body of the letter should be approximately 180-200 words.

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