Chiropractor Review Appointment

Chiropractor: Dr. Emily White Date: 1 November 2024 Subjective: - Patient reports significant progress towards treatment goals, rating overall improvement at 7/10. She notes a considerable reduction in chronic lower back pain and improved mobility. - No specific modifications to the treatment plan were requested by the patient at this time, as she feels the current approach is effective. - Current symptoms show continued improvement. The patient describes the previous dull, aching pain in her lumbar spine as now only occasional and mild, primarily when sitting for extended periods. There is no radiating pain. - Activity levels have increased significantly. The patient has resumed daily walks of 30 minutes, which she was unable to do previously. She also reports less discomfort during her office work. - No neurological changes reported; no weakness, pins and needles, numbness, or coordination issues. - No associated systemic or focal symptoms were reported. - The patient mentioned she has been more diligent with her home exercises, specifically the pelvic tilts and core strengthening exercises, which she believes has contributed to her improvement. - She finds applying a heat pack to her lower back after work to be very alleviating. Prolonged sitting at her desk tends to worsen symptoms, but they quickly resolve with movement. - Symptoms have steadily improved since the last visit, with fewer flare-ups and less intensity when they do occur. - No new family or social information was provided. - Referral path confirmed as self-referral, and the patient has no connections to others attending the clinic. Objective: - Vitals: BP 120/80 mmHg, HR 72 bpm. - Neurological assessment: Deep tendon reflexes (L2-S2) 2+ bilaterally and symmetrical. Intact sensation to light touch in all dermatomes. No motor deficits noted with full strength (5/5) in bilateral lower extremities. Balance is good. - Physical examination findings: - Cx flexion: Full ROM - Cx extension: Full ROM - Cx rotation L: Full ROM - Cx rotation R: Full ROM - GH pattern 1 (IntRot, extension) L: N/A - GH pattern 1 (IntRot, extension) R: N/A - GH pattern 2 (ExtRot, flexion) L: N/A - GH pattern 2 (ExtRot, flexion) R: N/A - MS Flexion: Full ROM - MS Extension: Full ROM - MS Rotation L: Full ROM - MS Rotation R: Full ROM - Single Leg Balance L: Stable for 30 seconds - Single Leg Balance R: Stable for 30 seconds - Deep Squat: Good form, no pain - Palpation of spine and joints for tenderness or abnormalities: Mild tenderness noted at L5/S1 sacroiliac joint on the right. No other significant findings. - Spinal alignment/restricted areas of motion: Subtle restriction in motion noted at the right sacroiliac joint. - Range of motion in affected and adjacent areas: Lumbar flexion and extension within normal limits but slightly restricted at end-range due to sacroiliac discomfort. Thoracic and cervical ROM full and pain-free. - Results of diagnostic tests: No new diagnostic tests or imaging reviewed during this visit. Diagnosis, Change of Plan: - Chiropractic diagnosis or functional assessment: Continued improvement in mechanical lower back pain with residual sacroiliac joint dysfunction (right). - Areas requiring adjustment or manipulation: Sacroiliac joint (right) requiring gentle mobilisation/adjustment. Lumbar spine for supportive mobilisation. - Plans for follow-up visits and continued care: Continue with weekly adjustments for the next 3 weeks, focusing on sacroiliac joint stability and lumbar mobility. Re-evaluate progress at that time. Change of Goals: - Concerns or preferences: Patient expressed a desire to incorporate more specific exercises to strengthen her core and gluteal muscles to prevent future recurrences. - Alterations to initial plan: The next few sessions will integrate new core and gluteal strengthening exercises into the home exercise programme. No change in visit frequency or primary technique at this stage. - Areas to focus on next appointment: Sacroiliac joint mobilisation, review of current home exercises, and introduction of new core stability exercises. Additional Notes: - Patient education: Patient was educated on proper lifting techniques and ergonomic adjustments for her workstation. Emphasised consistency with home exercises and provided a handout for new core strengthening exercises. - Family and social information: No updates on family dynamics or supports. - Referral path: Not applicable for re-documentation. - Clothing instructions: Patient advised to wear loose, comfortable clothing for future appointments to facilitate examination and treatment. - Follow-up and continued care: Next appointment scheduled for 1 week from today. Review of progress planned for 22 November 2024. - Concerns or preferences: Addressed patient's request for more targeted strengthening exercises by integrating them into the next phase of treatment. - Alterations to plan: New exercises to be introduced; no other significant alterations. - Areas to focus on next appointment: As above, sacroiliac joint, home exercise review, and new core exercises. - Internal referrals: No internal referrals made at this time.