TASK 57:
Patient Name: Stanley Williams.   D.O.B – 20.03.1956

Patient History– Stanley Williams is a Builder and regular patient your country medical centre in Mildura, 350 km north of Melbourne. Present occasionally with lower back pain clears no with anti inflammatories. Had spinal X-ray 1 year ago – showed some narrowing of L4-5 and sign of osteoarthritis in L5-ST)

las NIDOM controlled by diet and exercise

23.02.2007: Sudden onset lower back pain yesterday while working. Worse than usual back pain.

Worse L side with radiation down back of L.thigh. Took Nurofen which settled pain but worse this morning. Couldn’t go to work puts hand on L hip when walking, Walks slowly. Tender around lower spine and spinal muscles. SLR positive on L side at 45 degrees. Legs normal power and reflexes. Pain inhibiting lumbar flexibility and extension

Assessment: Possible disc prolapse or nerve root irritation from facet joint dysfunction

Treatment: Bed rest 2 days, paracetamol and anti inflammatory 50 mg and daily with food, hot water bottle on back, come back in 2 days

25.02.2007: No change in pain in the back or leg pain, neurological examination done

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

Assessment : No improvement of symptoms but no worsening

Treatment: Continue treatment as before.NSAIDS increased to 3 x daily. Return in 2 days for review

27.02.2007: No change in back pain, radiating leg pain worse, most constant, esp at night, urine test showed glycosuria 2 + (usually none). Obviously in pain, difficulty with movement, walks slowly. Still tender and with decreased motion. SLR 30 degrees L side. Random blood glucose taken 12 mmol worse.

Assessment: Symptoms worse. Inactivity making diabetes symptoms. Treatment: Continue treatment as before Review in 5 days. Paracetamol/Codeine 30 mg x 6 hourly. Reason for diabetes symptoms worsening exolained diet modification recommended because of inactivity

29.02.2007: Called urgently to patient’s home, pain increased overnight in back and down L.leg, pain not controlled by any medications, lower Leg has become numb.

-Pain caused inability to get out of bed. SLR 10 degrees L.leg and 30-40 degrees R. leg. L. leg also no ankle reflex, decreased toes extension, decreased ankle flexion, decreased pin prick sensation in areas. Random blood glucose increased to 14mmol

Assessment – Condition not relieved by medications Signs Indicate nerve root compression and disc prolapse

Treatment: Ambulance transport to Royal Melbourne Hospital emergency department arranged, phoned orthopaedic registrar and arranged for hospitalisation and orthopaedic assessment.

Writing Task: Using the information in the case notes, write a letter of referral to Dr. Kate Murray, Royal Melbourne Hospital, Grattan Street, Royal Park 3054

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