EMI.AI

Current update

27/08/2025

Patient Symptom & Progress Report
Date: 27 aug 2025
Patient Name:

To: doctor

Dear Doctor,

I am providing an update on my ongoing condition and symptoms, which have persisted for over 12 months following my original injury.

Current Symptoms

  • Lower Back and Nerve Pain
    • Ongoing numbness and burning sensation in the lower back.
    • Protruding, shooting, electric shock–like pulse pain radiating from the right S1 region, across to the left S1, and down into the left leg and foot.
    • Persistent numbness and tingling affecting several toes.
    • Occasional itching sensations in the left leg and foot.
  • Sitting Tolerance
    • Pain increases significantly when sitting, particularly on hard surfaces (e.g., car seats).
    • Soft or padded cushions are required to tolerate longer periods of sitting.
    • Able to sit for approximately 20 minutes before numbness, burning pain, and pulsing sensations force me to stand and walk.
    • Relief requires walking for 10–15 minutes before pain eases enough to resume activity.
  • Sleep Issues
    • Unable to sleep on my left side due to increased pulse-like pain radiating down the left leg.
    • Pain extends into the hamstring, behind the knee, sometimes over the front/top of the knee, and continues into the foot and three toes.
    • Pain is present daily, 24/7, with varying intensity.
  • Mobility Problems
    • Climbing hills: unable to continue beyond ~2 house legth 60- 80 meter hill incline
    • before left leg begins dragging.
    • Episodes of sudden loss of leg control:
    • the left leg either folds behind me or drops during stepping,
    • leading to near-falls or actual falls.
    • Left hip bursitis: improved but not 100% resolved.
  • Other Symptoms
    • General muscle loss across the body and noticeable overall weight loss.
    • Occasional headaches.
    • Concerns remain regarding potential nerve damage.

Treatment Response

  • Osteopathy and activity adjustments sometimes aggravate symptoms initially.
  • Occasionally, delayed benefit is experienced: improvement may appear up to 72 hours after treatment. this is normal since injury delay effect even with dry needle.
  • At other times, pain persists until the next follow-up visit.

Questions and Concerns

  1. If nerve damage is confirmed, what would be the next steps in treatment/management?
  2. Why does pain remain more than 12 months after the initial injury has healed?
  3. needed updated imaging (MRI/X-ray) be performed to assess ongoing symptoms and for neurosurgeon review in september

Requests

  • Referral for MRI scan (and X-ray if required) in September.
  • Updated work capacity certificate.
  • Advice regarding safe modifications to my gym and osteopath programs.

Work Status

  • My workplace is expected to reopen in early October 2025.
  • At present, I am still unable to return to work due to persistent symptoms and functional limitations.

Thank you for your continued care and guidance. I would appreciate your recommendations on the next steps, further imaging, and management of these ongoing symptoms.