.
10th March, 2023
MEDICAL
REPORT
S. S, 63YEARS, FEMALE
WCA/6070/2023
Diagnosis: Degenerative disease of the lumbosacral spine
Background Information:
The above-named is a 63yr old female
known but controlled hypertensive and diabetic presenting today with 10yrs history
of insidious onset of low back pains which has become increasingly radicular.
Pain is exacerbated by standing and walking a distance and relieved by sitting
and resting. Recently, her walking
distance has reduced considerably and thus affecting her quality of life
significantly. This has become a source of concern for herself and her family.
Hence, she is seeking medical help now. It is also important to note that
there’s history of trauma to the back 25yrs ago.
Neurological
Examination
O/E: normal tone, power, reflexes and sensation on
both lower limbs. However, there’s significant limitation in a straight leg
raising due to pain on her low back.
Radiological
investigation:
X-ray
of spine shows reduction in disc height at L3/L4, L4/L5, L5/S1, but worse at
the last lower levels. There’s associated straightening of the lumbar spine.
MRI
of the lumbosacral spine shows disc herniation at the above mentioned level
bilaterally. This features are in keeping with advanced degenerative disease of
the lumbosacral spine.
Management Plan:
·
To
counsel on surgery as definitive treatment
·
Ensure
Blood Pressure, Blood Sugar, Lipid Profile, and General medical condition to be
normal.
·
Antiplatelet
to be stopped if we are planning for surgery
·
To
consider less invasive options if patient is undecided at this time:
1.
Medications
(pain relievers)
2.
Physiotherapy
3.
Epidural
injection
Pros
and cons of different surgical and medical treatment has been explained but she
has a preference to consider surgical options at the moment.
She
will further discuss with her family. And following this,
we also had a meeting with the family on this matter after which they needed
time to think through and take a definitive stand and advice us accordingly.
Kindly revert for further clarifications
if need be.
Sincerely Yours,
Dr. Halima Ibrahim
For Team Wellington Clinics
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