Sims and Finn Chiropractic Note

[Patient name and/or file number] Jane Doe, File #12345 Today's Condition: Patient reports feeling some relief from the previous chiropractic treatment, with a reduction in lower back pain. Patient presents today with complaints of persistent lower back pain and stiffness, which has been ongoing for the past two weeks. She reports that the pain is worse in the mornings and after prolonged sitting. The pain is described as a dull ache, rated a 6/10 on the pain scale, located in the lumbar region. It is aggravated by bending and twisting motions. The onset was gradual, and the pain is constant with intermittent sharp spasms. Patient reports no specific injury, but the pain started after a weekend of gardening. She denies any radiating pain or numbness. Patient denies any neurological symptoms. She reports no previous injuries. She has a history of mild scoliosis diagnosed in adolescence. Patient has no significant past medical or surgical history. Patient is a desk worker, sits for long periods, and does not regularly exercise. She reports sleeping 7-8 hours per night and experiences moderate stress levels. Patient is not currently taking any medications or supplements. Patient's mother has a history of osteoarthritis. Examination: Physical examination revealed limited range of motion in lumbar flexion and extension. Palpation revealed tenderness in the lumbar paraspinal muscles. Orthopedic tests, including the straight leg raise, were negative. Muscle strength and reflexes were within normal limits. Vital signs: Blood pressure 120/80 mmHg, pulse 72 bpm, temperature 37°C. Chiropractic Adjustments/Treatment: Chiropractic adjustments were performed to the lumbar spine. Specific adjustments included a diversified technique to L3-L5. The patient also received soft tissue therapy to the lumbar paraspinal muscles. No dosages or units were relevant. Patient reported immediate relief of some stiffness and a reduction in pain level to 4/10 during treatment. Response to Treatment: Patient reported feeling more relaxed and less pain immediately following the treatment. Home Advice: "10–15 minute walk post adjustment" Patient was advised to apply ice to the affected area for 20 minutes, three times a day. She was also instructed to perform gentle stretching exercises and to maintain good posture while sitting. Follow-up: Patient is scheduled for a follow-up visit in one week.