Chiropractor's Note - Chief Complaint
GOALS: Patient expresses a desire to return to playing golf pain-free within the next three months and improve overall spinal mobility.
STRESSORS: Patient reports increased work-related stress due to tight deadlines, contributing to poor posture and muscle tension.
LOVE LANGUAGE: Patient mentioned that acts of service, such as their partner doing chores, make them feel most appreciated.
LOC: Cervical spine, specifically the neck and upper back.
ONSET: 1 November 2024, approximately two weeks ago, after prolonged computer use and then lifting a heavy box incorrectly.
CHAR: Dull ache, described as a constant, stiff sensation, occasionally sharp with certain movements.
FREQ: Constant, daily, worsening throughout the workday and easing slightly after rest.
RAD: Radiates to the left shoulder and down the left arm, stopping above the elbow.
EXAC: Prolonged sitting, looking down at a phone, and lifting objects.
REM: Heat packs, gentle stretching, and over-the-counter ibuprofen (which provides temporary relief).
Pr HX: History of minor whiplash injury 5 years ago, resolved with chiropractic care. No other significant medical history.
Pr RX: Applied heat and cold packs, took ibuprofen 400mg twice daily, and attempted self-massage. Ibuprofen provides mild, temporary relief.
MED: Ibuprofen 400mg PRN for pain, multivitamin daily. No other prescribed medications.
SH: Patient is a 45-year-old male, works as a software engineer, spends 8-10 hours daily at a computer. Exercises occasionally (walking). Non-smoker, drinks alcohol socially (2-3 units per week). Family history of osteoarthritis in mother.
Sx rev: Denies fever, chills, numbness, tingling beyond the left arm, weakness, bowel or bladder changes, or other systemic symptoms.
WORKING DX: Cervicalgia with radicular symptoms, likely due to cervicothoracic junction dysfunction and muscle hypertonicity.
Subluxation at C5, C6, T1, and T2.
Associated hypertonicity at trapezius, levator scapulae, and rhomboids bilaterally.
Associated postural change: Forward head posture and rounded shoulders.
Associated degenerative change: Mild degenerative disc disease noted at C5-C6 on previous imaging.
IMAGING FINDINGS: Recent X-rays (dated 28 October 2024) show reduced cervical lordosis and minor osteophyte formation at C5-C6, consistent with mild degenerative changes. No acute fractures or dislocations observed.
GOALS: [patient's goals] (Describe the patient's stated goals, aims, or objectives for their health, treatment, or overall well-being. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
STRESSORS: [identified stressors] (Document any identified stressors, including emotional, physical, environmental, or social factors that may be impacting the patient's condition or well-being. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
LOVE LANGUAGE: [love language] (Detail the patient's preferred method of expressing and receiving appreciation and affection. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
LOC: [location of complaint] (Specify the precise location of the patient's primary complaint or symptom. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
ONSET: [onset details] (Describe the date, time, and circumstances surrounding the initial appearance or development of the patient's symptoms or condition. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
CHAR: [symptom character] (Characterise the nature, quality, and sensation of the patient's symptoms, such as sharp, dull, throbbing, burning, etc. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
FREQ: [symptom frequency] (State the frequency and pattern of occurrence of the patient's symptoms, e.g., constant, intermittent, daily, weekly. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
RAD: [radiation pattern] (Document any radiation or spread of the patient's symptoms to other areas of the body. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
EXAC: [exacerbating factors] (Identify any factors or activities that exacerbate or worsen the patient's symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
REM: [relieving factors] (Note any factors or interventions that alleviate or improve the patient's symptoms. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Pr HX: [past medical history] (Document the patient's relevant past medical history, including significant illnesses, injuries, and hospitalisations. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Pr RX: [previous treatments] (List any previous treatments or therapies the patient has received for the current or related conditions, including their effectiveness. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
MED: [current medications] (Itemise all current medications the patient is taking, including prescription drugs, over-the-counter medications, and supplements, along with dosages and frequency. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
SH: [social and lifestyle history] (Describe the patient's social history, including lifestyle factors, occupation, habits, and any relevant family history of medical conditions. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
Sx rev: [review of systems] (Provide a comprehensive review of systems, documenting any associated symptoms or concerns across different bodily systems not already detailed. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
WORKING DX: [working diagnosis] (State the preliminary or working diagnosis based on the information gathered. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
"Subluxation at" [vertebral levels] (Specify the vertebral level(s) or joint(s) where subluxation is identified, detailing the specific segments involved. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
"Associated hypertonicity at" [muscle groups] (Identify the muscle groups or anatomical regions where hypertonicity is observed in conjunction with the subluxation. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
"Associated postural change" [postural deviations] (Describe any noticeable changes or deviations in the patient's posture that are associated with the identified subluxation or other clinical findings. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
"Associated degenerative change" [degenerative findings] (Document any observed or reported degenerative changes in joints or tissues that are associated with the patient's condition. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
IMAGING FINDINGS: [imaging results] (Summarise the significant findings from any imaging studies, e.g., X-ray, MRI, CT, that have been performed, including relevant observations and interpretations. Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.)
