Dr John Paul
Alfred Melbourne hospital
Commercial road Melbourne
Dear Dr Paul,
Re: Mr Felix Nicholas, aged 21
Mr Felix Nicholas, who is suspected to have nerve root compression and disc protopse. He is being transferred to your facility for Orthopedic assessment and management.
Mr Nicholas is a builder, who is a regular patient in our medical center. He presented with lower back pain which was treated with anti-inflammatory medicines. His x-ray revealed narrowing of L3-4 and signs of osteoarthritis in L5- s. In addition, he has NIDDM and controlled with diet and exercise.
On 22 March 2008, Mr Nicholas visited with the complaint of onset of lower back pain which was radiating to left thigh. He was commenced on analgesics. His SLR positive on left side at 45 degree anti-inflammatory medicines, hot water bottle and bed rest were provided.
After 4 days Mr Nicholas revisited with warsened symptoms with decreased motion. His urine test shaved glycosuria 2t. Diet modifications and exercise were recommended for increased blood glucose. Alone with he was prescribed paracetamol and codeine for pain.
Today, emergency call was received from Mr Nicholas due to increased overnight pain which was not controlled with medications. On examination,his left lower leg was numb with no ankle hexion. His blood glucose recorded as 14mmol.
In view of the above, it would be greatly appreciated if you could provide emergency orthopedic assessment and management.
Should you require any further information, please do not hesitate to contact me.
2. Mr Felix Nicholas - Ansu Baby