Read the case notes and complete the writing task which follows.

Notes:

Assume that today's date is 30 August 2019.

Your patient, Sophie Bennett, is about to go on vacation and requires transfer to a local physiotherapist.

PATIENT DETAILS:

Patient:                         Ms Sophie Bennett
DOB:                               14 Nov 1969 (49 y.o.)
Occupation:                  Nurse

Current history:

20 Aug 2019

• Lifting heavy object at work, sharp pain (P) for one hour
• Kept going but by end day P++. P now radiating into R leg
• Couldn’t sit; tried to get up at 2am, couldn’t move, took ½ hr to urinate
• Unable to sit, even on toilet
• Cuada equina syndrome (CES) red flag questions checked. No onward ED referral was required

21 Aug 2019

• To Dr – Dr Greta Langley. Panadeine Forte, meloxicam NSAID (Mobic), benzodiazepine (Valium) prescribed

22 Aug 2019

• P easing, continuing medications, avoiding sitting

28 Aug 2019
Presenting complaint:

• R buttock/posterior thigh pain – constant and gripping. Intermittent numbness in sole of R foot, on outer border of ankle and great toe
  

Aggravating factors:

• Sitting, coughing/sneezing, putting on shoes/socks
• R leg/buttock pain is 8/10 at worst and subsides to 4/10 at best, in P as day progresses
  Night: Can’t turn, woken x3 night
  Day: Worse as day progresses
  

Relieving factors:

• Heat (hot water bottle)
• Medication (as per prescription)
• Standing up (if sitting)
• Lying down (especially pron

AROM lumbar spine:

• Flexion: 50cm from floor (P) Extension: No active extension (P)

Palpation:

• R low lumbar paravertebral tenderness and spasm
• R buttock tenderness and spasm
• L5 central posterior/anterior (PA): ↑P +++
• L3 and L4 central PA: ↑P +
  

Straight leg raise:

• R 35° P ↑back/leg (positive ankle dorsiflexion)
• L 80° (limited by L post thigh tightness)

Reflexes:

• R=L=NAD ankle, knee

Sensation:

• ↓Light touch over R little toe; remainder NAD

Power:

• L2 to S1 NAD

Action taken:

• Education re diagnosis of disc injury probable L4/5. No serious neurological signs
  but numbness (intermittent)
• Prone lying: repeated extension push up on elbows – improved lumbar flexion
  and reduction in leg pain
• Nil manual techniques performed due to irritability

Recommendations:

• Limit sitting – to use a lumbar roll
• Lie prone with extension routine hourly x10 when awake over next 2 days
• See Dr – change medication to tramadol (morphine-like narcotic) Reviewin 2 days

30/08/19

• Review appointment
• 50% ↑in mobility, 50% ↓in P
• Straight leg raise (SLR) R 50° P limits
• Able to lie prone with comfort. Able to open bowels OK

Recommendations:

• Continue prone extension exercises x10 every hr
• Pelvic floor exercises & transversus abdominis exercises x5 every hr
• To see physio in 2 wks
• Dr has reviewed medication. Off Pandeine Forte, onto tramadol
• Pt taking vacation (4 wks) to spend at beach house in Sandy Beach
• Requests transfer to physio nearb

Writing Task:
Using the information in the case notes, write a letter of referral to a fellow physiotherapist, Dr White, outlining the
presenting complaint and treatment to date. Address the letter to Dr Maggie White, Golden Sands Physiotherapy, 987
Main Rd, Sandy Beach.

In your answer:

•  Expand the relevant notes into complete sentences
•  Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words.