Subject: Documentation of New Symptoms and Symptom History (Back Pain) Dear Dr
I am writing to document my recent symptoms and relevant history, to ensure there is a complete record before my upcoming hospital referral. This is intended for your records and for the hospital to reference during future consultations.
- 25 September 2025
Consulted GP
- Blood tests showed abnormal results → received advice: “eat a healthy diet.”
- About a week prior (mid-September): experienced pain in the lower part of the right knee when using stairs.
- Frequency: Pain occurred about 2–3 times during the week.
- Pain intensity: Mild pain, occurring occasionally when using stairs.
Reported to GP; subsequently referred to physiotherapist.
- 17 November 2025
First appointment with physiotherapist
- Started weight reduction program.
- Physiotherapist performed initial assessment and guided exercises.
- 24 November 2025
- During exercises, it is suspected that the patella (kneecap) may have shifted out of place and was realigned back to its proper position.
- The previous stair-related pain seemed to resolve after this realignment.
- 9 February 2026
Physiotherapy follow-up
- Body weight had decreased by approximately 8 kg
- Despite weight loss, I noticed an increased feeling of heaviness in both calves, which felt heavier than before, especially after prolonged activity.
- Right knee overall condition stable.
- Physiotherapist noted asymmetry between knees (right knee outward) → advised further specialist evaluation / hospital referral.
- 13 February 2026 (Symptoms repeated over three days)
New symptom in left knee (different from the previous issue in the right knee)
- Triggered when squatting or when my thigh is close to my calf.
Note: This will be demonstrated in person.
- Pain intensity: Sudden and much stronger compared to the previous issue in the right knee, lasting a shorter time but requiring me to sit down immediately to relieve it. I cannot maintain the position when the pain occurs.
- Brief numbness/tingling or leg weakness (~1 second), resolves upon sitting.
- Frequency of occurrence: The symptoms occurred 3 times over the past 3 days, typically triggered by squatting or bending down.
- Effect on daily activities: The pain and weakness significantly affect my ability to squat and bend down. I also find it difficult to walk or stand for prolonged periods, as the pain forces me to stop and sit down.
- Around 20 February 2026 onwards
Onset of back pain
- Squatting requires keeping back straight: To avoid exacerbating the pain, I need to keep my back straight when squatting or performing similar movements.
- Pain location: The pain is concentrated in my lower back, specifically around the lumbar region, just above the hips.
- 22 February 2026 (Sunday night at 10:00 PM)
Pain worsened
- The pain in my lower back became much more severe around 10:00 PM, making it extremely difficult to sleep.
- I could not fall asleep due to the intensity of the pain and the discomfort. The next morning, on 23 February, I was unable to wait any longer due to the exhaustion from both the pain and lack of sleep.
- As a result, I went to the MIU (Minor Injuries Unit). However, they only advised me to go to a pharmacy for over-the-counter medication.
- Then, I went to the UTC (Urgent Treatment Centre), seeking immediate intervention for pain relief.
- 23 February 2026
Persistent back pain and worsening symptoms
- The pain in my lower back continued to be severe throughout the day. I attempted to lie on the bed to rest, but I could not fall asleep due to the pain. Turning over in bed caused increased discomfort.
- While in the hospital, I noticed that the pain worsened during certain movements, such as when taking the elevator. Specifically, the pain intensified when the elevator accelerated or decelerated.
By the end of the day, the pain had become continuous and relentless.
- Questions for the Doctor
9.1. Medication Supply: Current medication will only last until Monday. What should I do if I run out before I can get more? Are there any alternatives or recommendations for managing the pain in the meantime?
9.2. Referral ?: Physiotherapist had previously recommended a referral. Given that my situation has changed, should I see the physiotherapist again, or should I update the referral details with the current information before proceeding further?
- Additionally, I’m uncertain if my current lower back pain is related to the previous knee issue. Could you provide any insight into whether the two are connected, and if so, what the next steps should be?
9.3. Osteopathy Consultation
- Is Osteopathy Suitable?: I am considering seeing an osteopath for further treatment. Based on my current condition, do you think osteopathy is a suitable treatment option for me?
- 3A: Would you recommend visiting an osteopath at this moment, and would a practitioner specializing in this be appropriate for my case?
- 3B: If osteopathy is not suitable at this time, when would be the best time to see an osteopath, and at what stage of my condition should I consider this treatment?
Sincerely,