Physical Therapist Initial

History of Present Illness John Doe, a 45-year-old male, presents to physical therapy with complaints of lower back pain that began insidiously three months ago. He reports no specific event that triggered the pain. Signs and Symptoms John describes his pain as a constant dull ache with occasional sharp twinges. Pain at present John rates his current pain as 6 out of 10. Aggravating and easing factors Aggs: Prolonged sitting, bending forward, and lifting heavy objects. Ease: Resting in a reclined position and applying heat. Activity Limitations John is unable to perform his usual gardening activities and has difficulty sitting for extended periods at work. Co-morbidities/Complexities Hypertension Prior treatments / surgeries John has tried over-the-counter pain medications and chiropractic adjustments with minimal relief. He is not seeing any other providers for this issue. Prior imaging /studies An MRI showed mild disc degeneration at L4-L5. Goals John aims to return to his gardening activities and sit comfortably at work without pain. OBJECTIVE - Posture: Slight forward head posture - Range of Motion: Limited lumbar flexion - Strength: Weakness in core muscles - Palpation: Tenderness over the lumbar paraspinals Assessment: John Doe presents with chronic lower back pain likely due to mild disc degeneration at L4-L5. His symptoms and functional limitations suggest he would benefit from skilled physical therapy to improve core strength and flexibility, which will help alleviate pain and restore function. GOALS - Improve lumbar flexion range of motion by 20 degrees within 8 weeks. - Increase core muscle strength to 4/5 on manual muscle testing within 10 weeks. - Sit comfortably for 2 hours without pain within 6 weeks. - Return to gardening activities for 30 minutes without pain within 12 weeks. - Reduce pain level to 3/10 during daily activities within 8 weeks. Plan: - Initiate a core strengthening and flexibility program. - Educate on proper body mechanics and posture. - Plan for follow-up in 2 weeks to reassess progress.