24th
April, 2023
MEDICAL
SUMMARY:
A.D.A 57 YEARS/ MALE
- WCA/6161/2023
Presentation/Neurology: A 57 year
old public servant who presented on account of right radicular low back pain x
3/12. He describes pain as dull aching, gradual in onset, radiates to the right
thigh and leg, aggravated by bending forward, relieved by painkillers,
severity-6/10. Hx of sedentary lifestyle, as he sits for long periods of time. He
is a known hypertensive diagnosed 7 months ago; regular on ex-forge and clinic
visits. Also, there is hx of trauma to the back which occurred about 30 years
ago, when he fell on his gluteal region from a tree. No hx of dysuria, nocturia
or frequency. He had a cervical x-ray done a year ago which revealed cervical
spondylosis.
Neurological
findings: Limitation of straight knee raise at the right side (LL). The rest of
the tone, power, reflexes are normal.
Neuroimaging and Diagnosis: Lumbosacral spine MRI shows a collapse of L4/L5 with dehydration of the disc from L3-S1. There is associated entrapment of existing nerves at those levels.
Treatment
and Follow up:
1.
Lumbosacral
MRI
2.
Review
with result of the scan
3.
Discuss
and counsel patient on his condition and treatment modalities.
4.
Lifestyle
modifications- weight reduction, graded exercises, pain management, advice
against carrying heavy objects.
5.
Physiotherapy
6.
See
the neurosurgeon in 3 months (25/07/2023) for follow up.
7.
Repeat
MRI in 6 months.
Kindly revert to us for more
inquiries if need be.
Yours Sincerely,
Dr. Modupeoluwa Olakunle
Motajo.
For: Team Wellington Clinics.
………………………electronically
signed to avoid delay in transmission.