Dr Matthew Sebastian

Royal Melbourne Hospital

Melbourne 3054

19.02.2018

Dear Dr Sebastian,
Re: Alex David, aged 45

Thank you for accepting Mr David into your care for further assessment and management due to a
possible nerve root compression and a disc prolapse. He is being sent via ambulance today.

Regarding Mr David’s medical history, he came to the medical centre occasionally because of his
lower back pain which was managed with painkillers and anti-inflammatory medication. One year
ago, an x-ray of his spinal showed narrowing and osteoarthritis in his lower spine vertebras.
Additionally, he keeps his diabetes symptoms with diet and exercises. he has diabetes.

On 12.02.2018, Mr David came to the clinic with severe back pain that was worse during his work.
The pain radiated up to his left thigh making him walk slowly and preventing him to from normally
flexing or extending his left leg. An SLR test was done which was positive around 45 degrees. In
addition, his lower spinal muscles were tender. Therefore, he was advised to have lots of bed rest
and continue his current medication.

Over the last week, he Mr David came back to the medical clinic twice complaining that the pain
became worse without any improvement even though his dose of medication increased. A blood
and urine test showed some abnormalities. As a result, his diabetes symptoms were exacerbated
because of his inactivity and a blood and urine test showed some abnormalities (such as?).

The urgent home visit today wasn’t mentioned

In view of the above, it would be greatly appreciated if you could find a diagnosis for diagnose and
treat Mr David’s condition and also a cure. If you require any information, please do not hesitate to
contact me.

Yours sincerely,

Registered Nurse

240

This letter is quite long and urgent. Therefore, I would start with today’s urgent visit. Then
summarise past visits. Then mention history.
1. Intro

2. Today, an urgent home visit was requested by Mr David as he could not get out of bed due
to……..On examination, a straight leg raise test showed… Please note that Mr David is a
diabetic and his current blood glucose is 14mmol because of recent inactivity associated
with his pain.

3. Prior to today, Mr David had presented on three occasions complaining of sudden lower
back pain which radiated to his left thigh that was worse while working. Initially, ……
However, ……. Therefore, his dosage of NSAIDS was increased, but these have been
ineffective in treating his pain. It’s important to mention the Mr David had an X-ray a year
ago that showed…

4. Based on the above, …