Sample answer by Lifestyle Training Centre

Dr Kate Murray,
Royal Melbourne Hospital
Royal Parl, 3004.

29/2/2007

Dear Murray,
Re: Mr Stanley Williams, 20/3/1956.

Mr Williams requires urgent orthopaedic assessment in emergency department as he is suffering from excruciating back and lower leg pain. He has signs of nerve root compression and disc prolapse; he is being brought to you by ambulance.

Mr Williams has been suffering from back pain, and the pain shot up overnight, which is not relieved by medication. He is now unable to get out of bed, and his lower left leg is numb. He has: decreased toes extension, decreased ankle flexion, decreased pin prick sensation in areas and no ankle reflex.

Mr Williams is a builder and has been suffering from occasional lower back pain, which usually clears up with anti-inflammatories. His year-old spinal x-ray shows narrowing of L4-5 and sign of osteoarthritis in L5-s1. He has NIDDM which is controlled by diet and exercise.

Mr Williams had visited our hospital from 25 to 27 of this month, reporting a sudden unusual onset lower back pain, radiating down the back of his left thigh. He has tenderness around his lower spine and spinal muscles. He experiences difficulty with movement, and the symptoms worsened day by day though he was commenced on medication and diet modification.

Based on the above, please hospitalize Mr Williams, providing urgent orthopaedic assessment and treatment. Should you have further queries, please do not hesitate to contact me.

Yours sincerely,
Registered Nurse.
(word count: 211)

Writing task

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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