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You are a Public health nurse in Boomsgrave health centre in Walsgrave CV2 4HF
Patient Name: Mr Lord Ellison
DOB: 20/04/1976
Address: 36, New Avenue road
Marcion
CH2 3 DP
Occupation: builder since 10 years
History: Regular patient in Boomsgrave health centre in Walsgrave CV2 4HF
occasionally present with lower back pain and takes anti-inflammatory
had spinal x-ray 2 years ago – some narrowing of L3- 4, signs of osteoarthritis
type -II DM controlled by diet and exercise
18/03/2018
Sudden onset of lower back pain while working.radiating to left side and then to the down
left thigh. Took ibuprofen which settled pain but worse this morning.
Didn’t go for work due to the pain.
Tenderness around the lower spine, walks slowly.SLR positive on left side at 45
degree.normal strength on both legs.pain inhibiting flexion and extension.
Assessment: possible disc prolapse
Treatment: Proper bed rest -3 days,paracetamol; 1 g, NSAIDs, hot water bottle on back, follow -up in 3 days.
21/03/2018
no change, neuro obs – normal
complaints of pain but no worsening
Assessment: No change in symptoms
Treatment: Continue treatment as before.NSAIDs increased to 4x daily, follow up visit after 3 days.
24/03/2018
Back pain, radiating pain in legs, especially at night. urine test- glycosuria 2 plus(NAD)
walk slowly, difficulty in movement, Random blood glucose-14 mmol
Assessment: symptoms worse .inactivity making diabetes symptoms worse
Treatment: Codeïne phosphate 30-60 mg x 4 hourly.diet modification recommended- diabetes
27/03 /2018
Urgent visit to the patient’s home. Pain increased overnight in the back and left leg. Pain
uncontrollable by oral medication.numbness on the left leg.
Unable to get out of bed.no ankle reflexes, decreased toe extension, pinprick sensation
decreased. blood glucose- 16 mmol
Assessment: uncontrollable y medication.? for nerve root compression and disc prolapse
Treatment: Arranged ambulance transport to Watford hospital emergency department, arranged an
orthopaedic assessment through phone.
Write a letter to Dr Koshy Sandik, Watford Hospital, Watford, Cv2 4DX
27/03/2018
Dr Koshy Sandik
Watford Hospital
Watford
Cv2 4 DX
Dear Dr Sandik
Re: Mr Lord Ellison, DOB: 20/04/1976
I am writing to transfer Mr Ellison to your facility for urgent hospitalisation and further orthopaedic assessment since he is suspected to have nerve root compression and disc prolapse.
Mr Ellison is a builder who has had narrowing of L3-4 and signs of osteoarthritis for two years, and his occasional back pain was managed conservatively. On 18/03/2018, he presented with sudden onset of severe back pain on his left side, which was radiated down to the back of the left thigh. On assessment, he had symptoms suggestive of the above-mentioned condition, and he was treated with symptomatically.
Last three days of consecutive visits showed that Mr Ellison had no change in his pain; however, it is not worse. He had difficulty in movement and walked slowly. He was received the same medication with an increased frequency of anti-inflammatory. In addition, he was recommended for diet modification since his inactivity leads to worse diabetic symptoms.
Today, Mr Ellison was visited urgently because his affected leg became numb, confined to bed, and the pain was uncontrolled by the prescribed medications. Examination revealed that decreased toe extension and decreased pinprick sensation with no ankle reflexes. Along with that, his blood glucose level increased to 16 mmol.
In view of the above, kindly provide immediate evaluation and intervention at the earliest.
Please contact me for further queries.
Yours sincerely
Public Health Nurse
Boomsgrave health centre
Walsgrave
CV2 4HF
