18TH
August, 2023.
MEDICAL REPORT
WCA/30YEARS/FEMALE
DIAGNOSIS: Multi level
disc degenerative disease L4/L5, L5/S1.
Background history and Presentation: Above named patient presented to this facility on account of severe
low back pain of 8yrs duration which has been progressively worsening. Low back
pain was insidious in onset, non radicular, aggravated by standing and walking,
only temporarily relieved by analgesics. Pain is severe enough to disturb her
daily activity.
No
associated weakness of the lower limbs, no associated fecal or urinary
incontinence.
Neurology: Neurology
essentially normal
MANAGEMENT
PLAN:
·
Counsel on lifestyle
modification
·
Epidural injection
PRE-
EPIDURAL INJECTION EVALUATION
VAS- 8/10
ODI: 56%
OPERATION NOTE
Lumbar Epidural injection carried out with
a cocktail of 80mg triamcinolone/ 4mls of 0.25% marcaine, injected into the
L4/5 epidural/lumbar space under fluoroscopy guidance.
Procedure was well tolerated.
See image below:
PLAN:
1.
Monitor patient for 1 hour
2.
Check ODI and VAS @ 2wks and 4wks
3.
Discharge home today
4.
Tabs cerebrex 200mg bd x 2/52
5.
Tabs lyrica 75mg dly x 2/52
See patient in 2 weeks (01/09/2023)
Kindly revert to us for further
clarification when necessary.
Yours Sincerely,
Dr. Ozoemena O.F
For Team Wellington Clinics Abuja
------electronically signed for ease of
transmission