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Detailed Explanation of this Medical Document
This is a Follow-Up Visit prescription from Yashoda Hospitals, written by Dr. Amarnath Reddy B (MBBS, MS, FDRA, FIPSE, EDPM), a Consultant Pain Management specialist with a European Diploma in Pain Medicine and Fellowship in Chronic Pain from the University of Toronto, Canada.
Patient Details
| Field | Information |
|---|---|
| Patient Name | Mrs. Patale Laxmi Bai |
| Age / Gender | 73 years / Female |
| YH No. | 116722280 |
| Date | 22/06/2026, 11:05 |
| Rec. No. | DFV1094263/26 GENERAL |
| Ref By | DOD |
| City | Kukatpally |
| Token / Slot / Room | Token 33A, Slot 11:40, Room 124 |
| Consultation Fee | Rs. 0 (waived) |
Initial Screening / Vitals
| Parameter | Value |
|---|---|
| HR (Heart Rate) | 87 beats/min |
| BP (Blood Pressure) | 126/70 mmHg |
| Temperature | 97.5°F |
| SpO2 | 98% |
These vitals are all within normal range for a 73-year-old female.
Complaints / Diagnosis (Handwritten Notes - Interpreted)
"Flulclo Left L4/L5 radiculopathy"
- This refers to a left L4-L5 radiculopathy - compression or irritation of the nerve root at the 4th and 5th lumbar vertebral levels on the left side, causing radiating nerve pain down the leg (sciatica-like).
- "Flulclo" likely refers to a procedure code or abbreviation used in the department (possibly fluoroscopic/caudal injection or a specific block).
"H/o low back pain + left LE radiculopathy - 1.5 months"
- The patient has a history of low back pain with left lower extremity radiculopathy for approximately 1.5 months.
Status on Follow-Up (Under "S/P" = Status Post / After Procedure)
"S/P ④ C0-S1 SNRB & Fluoroscopy"
- The patient had ④ (4) C0-S1 Selective Nerve Root Blocks (SNRB) guided by fluoroscopy.
- SNRB is an injection of local anesthetic and/or steroid around a specific spinal nerve root to reduce inflammation and pain.
"Doing well"
- Patient's general condition is improving.
"Reports 50-60% relief in pain"
- Significant pain relief after the procedure - the patient reports 50 to 60% reduction in pain.
"Able to ambulate better"
- Patient can walk better than before the treatment.
Remaining / New Complaints
"But still H/o ④ LE dragging pain from ① gluteal, left thigh + no calf"
- There is still some dragging (dull, heavy pulling) pain in the left lower extremity, specifically in the gluteal region (buttock) and left thigh, but no calf pain (no calf involvement, which is a good sign - rules out more distal nerve involvement).
"Neck walling, sleep disturbance ⊕"
- "Neck walling" likely means neck stiffness or neck tightness - patient also has sleep disturbance (positive finding).
"④ ⊕ my trigger finger" (or may read as "④ ⊕ trigger finger")
- Patient also has a trigger finger (a condition where a finger gets stuck in a bent position due to inflammation of the tendon sheath).
On Examination (O/E)
"SLR R 20" (Straight Leg Raise test positive at ~20°)
- SLR (Straight Leg Raise) is a clinical test for lumbar nerve root compression. A positive result at 20 degrees on the right side indicates significant nerve irritation - this is a low-angle positive, suggesting notable lumbar radiculopathy.
"L 30 ① gluteal tenderness ⊕"
- SLR on the left side is positive at 30 degrees, with positive gluteal tenderness (tenderness over the gluteal/buttock region on palpation).
"Sq SLR ⊕" (Slump or Seated Straight Leg Raise - positive)
- Another nerve tension test confirming neural involvement.
Plan / Next Steps (Partially readable)
"Review ETL - Up to date" (or similar)
- Likely refers to reviewing investigations or a follow-up timeline.
Clinical Summary in Plain Language
Mrs. Laxmi Bai, a 73-year-old woman from Kukatpally, came for a follow-up visit to the Pain Management clinic at Yashoda Hospitals. She has been suffering from low back pain radiating to her left leg (L4-L5 radiculopathy) for about 1.5 months.
She previously received 4 selective nerve root block injections under fluoroscopy guidance, which gave her 50-60% pain relief and improved her ability to walk. However, she still has some dragging pain in her left buttock and thigh, along with neck stiffness, sleep difficulties, and a trigger finger.
On examination, her straight leg raise tests are positive bilaterally at low angles (20° right, 30° left), with gluteal tenderness on the left - all consistent with ongoing lumbar nerve root irritation.
The doctor is monitoring her condition and planning further management accordingly.
Note: This document contains handwritten clinical notes in a doctor's shorthand. Some words have been interpreted based on medical context. For any treatment decisions, always consult the treating physician directly.
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