Patient Information:
- Name: John Smith, Date of Birth: 12/05/1978, Address: 123 High Street, Anytown, AB1 2CD, Contact Information: 01234 567890
- Employment status: Works as a builder, Physical demands of job: Heavy lifting and repetitive movements, Work-related activities: Lifting, carrying, and bending.
- General exercise and activity levels: Walks the dog daily, enjoys gardening.
Medical History:
- Existing and past medical conditions: Lower back pain for 2 years, treated with physiotherapy previously.
- Details of previous surgeries/treatments: None.
- Allergies: None known.
- Current medications: Ibuprofen as needed for pain.
- Family medical history: Father with a history of osteoarthritis.
Social History:
- Smokes 10 cigarettes per day, drinks alcohol socially.
Current Condition/Complaint:
- Detailed description of primary injury, problem, complaint, or symptom: Acute lower back pain following lifting a heavy object at work. Pain is described as a sharp, stabbing pain in the lower back, radiating to the left buttock. Pain is worse with movement and prolonged sitting.
- Date of onset and/or date of surgery: Onset 28 October 2024.
- Description of how the injury occurred or complaint began: Lifted a heavy box at work.
- Details of any prior therapy, interventions, and/or surgery: Previous physiotherapy for lower back pain two years ago.
- Describe progression of complaint and nature of symptoms: Pain has worsened over the past few days. Pain is aggravated by bending, lifting, and twisting. Pain is relieved by rest.
Patient Goals:
- Short-term physiotherapy goals and time frame for achieving these goals: Reduce pain and improve mobility within 2 weeks.
- Long-term physiotherapy goals and time frame for achieving these goals: Return to full work duties and prevent recurrence within 3 months.
Objective:
- Physical examination details: Lumbar spine range of motion limited in flexion, extension, and lateral flexion. Palpation reveals tenderness over the lumbar paraspinal muscles. Positive slump test.
- Observations, tests, and measurements by the therapist: Visual gait analysis showed an antalgic gait. Numeric Pain Rating Scale (NPRS) score of 7/10 at rest.
- Specific measurements and assessment findings: Lumbar flexion: 30 degrees (normal 60 degrees), Lumbar extension: 10 degrees (normal 20 degrees).
Treatment:
- Educational treatment: Provided education on pain management, posture, and body mechanics.
- Hands-on treatment: Soft tissue massage to lumbar paraspinal muscles, Grade II PA mobilisation at L4/5.
- Active therapy treatment: Core stability exercises, pelvic tilts, and gentle lumbar range of motion exercises.
Assessment:
- Therapist's professional opinion based on subjective and objective findings: Acute lumbar strain with associated muscle spasm.
- Prioritized problems list: Pain, limited range of motion, muscle spasm.
- Progress towards stated goals: Patient reported a slight reduction in pain after treatment.
- Factors affecting progress and any need for modification in the plan: Smoking and heavy physical demands at work may be hindering progress. Plan will be modified to include advice on smoking cessation and work modifications.
Plan:
- Detailed treatment plan including interventions, frequency, and duration: Continue with soft tissue massage, mobilisation, and active exercises. Advised to attend physiotherapy twice a week for the next 4 weeks.
- Anticipated goals and expected outcomes: Reduction in pain, improved range of motion, and return to work.
- Equipment required and its usage: None.
- Education strategies for the patient: Education on posture, body mechanics, and pain management strategies.
- List home exercise program (HEP) provided, including details like reps, sets, and frequency: Core stability exercises: 3 sets of 10 repetitions, Pelvic tilts: 3 sets of 10 repetitions, Gentle lumbar range of motion exercises: 5 repetitions in each direction, performed 3 times a day.
- Referrals to other professionals: Advised to consult with occupational health for work modifications.
Patient Information:
- [Name, Date of Birth, Address, Contact Information.] (Only include Name, Date of Birth, Address, and/or Contact Information if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Employment status, Physical demands of job, Work-related activities.] (Only include employment status, physical demands of job, and/or work-related activities if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [General exercise and activity levels.] (Only include general exercise and activity levels if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Medical History:
- [List existing and past medical conditions, e.g., osteoporosis, stroke, high blood pressure, etc.] (Only include existing and past medical conditions if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Details of previous surgeries/treatments.] (Only include details of previous surgeries/treatments if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Mention any allergies.] (Only include allergies if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Mention current medications including over-the-counter or herbal supplements.] (Only include current medications if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Mention family medical history of disease that may impact therapy.] (Only include family medical history if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Social History:
- [Mention relevant social history like lifestyle factors, including tobacco and alcohol use, that may affect therapy.] (Only include relevant social history and lifestyle factors if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Current Condition/Complaint:
- [Detailed description of primary injury, problem, complaint, or symptom.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Date of onset and/or date of surgery.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Description of how the injury occurred or complaint began.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Details of any prior therapy, interventions, and/or surgery.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Describe progression of complaint and nature of symptoms.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Patient Goals:
- [Short-term physiotherapy goals and time frame for achieving these goals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Long-term physiotherapy goals and time frame for achieving these goals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Objective:
- [Physical examination details.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Observations, tests, and measurements by the therapist.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Specific measurements and assessment findings.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Treatment:
- [List all educational treatment that was provided throughout the session, e.g. pain science education.] (Only include educational treatment if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely. Only include treatments administered within this session. Never include previous or future planned treatments.)
- [List all hands-on treatment provided throughout the session, e.g. Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc.] (Only include hands-on treatment if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely. Only include treatments administered within this session. Never include previous or future planned treatments.)
- [List all active therapy treatment provided throughout the session, e.g. 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc.] (Only include active therapy treatment if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely. Only include treatments administered within this session. Never include previous or future planned treatments.)
Assessment:
- [Therapist's professional opinion based on subjective and objective findings.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Prioritized problems list.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Progress towards stated goals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Factors affecting progress and any need for modification in the plan.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Plan:
- [Detailed treatment plan including interventions, frequency, and duration.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Anticipated goals and expected outcomes.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Equipment required and its usage.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Education strategies for the patient.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [List home exercise program (HEP) provided, including details like reps, sets, and frequency.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Referrals to other professionals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
(For each section above, only include content if it is explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the section entirely. Never hallucinate, infer, or assume details. Do not state that information is missing—simply leave out any section or placeholder without explicit supporting information. Use only the transcript, contextual notes, or clinical note as reference for all content. Use as many lines or paragraphs as needed to capture all relevant information.)
