RACGP Medical Report

Administrative Details

• Date of request: 01/03/2025
• Received from: WorkSafe Victoria (via Allianz Australia)
• Claim number: WSV-2025-884920
• Patient name: Marcus James Vance
• Patient date of birth: 14/08/1982
• Practice name: Bayside Family Medical Centre
• GP name: Dr Sarah Jenkins
• GP credentials: MBBS, FRACGP

General Practitioner Credentials

• Report Prepared By: Dr Sarah Jenkins, MBBS, FRACGP

This report was prepared by Dr Sarah Jenkins, MBBS, FRACGP, with 12 years of experience in general practice. I have provided care to Marcus James Vance since 10/05/2018, and I am their usual GP.

Purpose and Scope

This report was requested by WorkSafe Victoria (via Allianz Australia) to supply medical information about Marcus James Vance's L4/L5 lumbar disc prolapse with right L5 radiculopathy. It draws on the medical records and describes the patient's condition, treatment, investigations, and referrals. The medical record may contain omissions.

Subjective Findings

Demographic and Contextual Factors

• 42-year-old male employed full-time as a logistics warehouse supervisor.
• Role requires frequent manual handling of freight (15–25 kg), repetitive bending, and prolonged standing on concrete surfaces.

Symptoms (Patient-Reported)

• Acute onset severe lower back pain radiating down the right posterior thigh and calf, with associated paraesthesia in the right great toe.
• Radicular pain has improved by approximately 40% since commencing physiotherapy and pregabalin; however, symptoms are exacerbated by sitting > 30 minutes or forward flexion.

Impact on Lifestyle

• Time Off Work: Unfit for all duties from 15/01/2025 to 05/02/2025 (3 weeks total).
• Functional Limitations: Unable to lift > 5 kg, avoid repetitive bending, twisting, or prolonged sitting/standing (> 30 minutes without a postural break).
• Workplace Adjustments: Returned to modified administrative duties on 06/02/2025 (4 hours/day, 3 days/week) utilising a sit-stand desk with zero manual handling.

Objective Findings

Medical History & Diagnosis

• Initial presentation on 15/01/2025 following an acute lifting injury at work on 14/01/2025.
• Right-sided lumbar radiculopathy secondary to L4/L5 disc prolapse, formally diagnosed on 20/01/2025 following MRI confirmation.

Test/Investigation Results

• CT Lumbar Spine (16/01/2025): Broad-based posterior disc bulge at L4/L5 with mild-to-moderate right neural exit foraminal stenosis.
• MRI Lumbar Spine (19/01/2025): Right paracentral disc extrusion at L4/L5 contacting and displacing the traversing right L5 nerve root. Normal conus medullaris.

Medical Management to Date

Medications

• Paracetamol (Panadol®) 1,000 mg PO QID (commenced 15/01/2025, changed to PRN on 12/02/2025).
• Meloxicam (Mobic®) 15 mg PO daily (commenced 15/01/2025, ceased 05/02/2025).
• Pregabalin (Lyrica®) 75 mg PO nocte (commenced 20/01/2025, titrated to 75 mg PO BID on 27/01/2025).

Referrals

• Referred to Mr David Chen (Physiotherapist) on 20/01/2025 for McKenzie protocol exercises and core stabilisation.
• Referred to Mr Alistair Vance (Neurosurgeon) on 05/02/2025 for specialist opinion regarding non-operative vs surgical management.

Hospitalisations

• Nil hospital admissions associated with this condition.

Procedures/Therapies

• CT-guided right L5 perineural corticosteroid injection performed on 10/02/2025.
• Weekly physiotherapy sessions (6 sessions completed to date).

Ongoing/Planned Management

Medications

• Pregabalin (Lyrica®) 75 mg PO BID ongoing for neuropathic pain; plan to wean over 4 weeks as radiculopathy resolves.
• Paracetamol (Panadol®) 1,000 mg PO QID PRN for flare-ups.

Referrals

• Initial neurosurgical consultation with Mr Alistair Vance scheduled for 25/03/2025 to review progress post-epidural steroid injection.

Hospitalisations/Procedures/Therapies

• Fortnightly physiotherapy focusing on functional restoration and work hardening.
• Transition to an exercise physiologist-led gym program planned for April 2025.

Prognosis

• Favourable prognosis for full recovery without surgical intervention, given the positive response to the perineural injection and physiotherapy. Expected to gradually return to pre-injury hours and duties over the next 3 to 4 months.

Medical Opinion / Response to Requested Questions

In my medical opinion, Mr Vance's L4/L5 disc prolapse is directly consistent with the mechanism of injury described at his workplace on 14/01/2025. His current functional capacity is restricted regarding domestic chores (unable to vacuum or mow lawns) and occupational duties. He currently has capacity for suitable duties 4 hours/day, 3 days/week, strictly observing a 5 kg lifting limit, no repetitive lumbar flexion/twisting, and alternating sitting/standing every 30 minutes. I anticipate upgrading his hours to 6 hours/day, 4 days/week at his next review on 20/03/2025, dependent on pain tolerance.

"I certify that the information contained in this report is accurate and complete." "This report will remain unchanged; however, I will supply a supplementary report with further detail if considered necessary."

Certification and Signature

GP's Name and Signature: Dr Sarah Jenkins [Signed Electronically] GP's Phone Number: (03) 9555 0192 GP's Email Address: s.jenkins@baysidemedical.com.au Date: 11/03/2025