Chiropractor Initial Consultation Appointment

Chiropractor Initial Consultation Appointment Subjective: Current Symptoms: Patient presents with acute low back pain. Started 25 October 2024, due to lifting a heavy box at work. Since onset: Pain has been constant, dull ache, with intermittent sharp pains on movement. Pain is located at the lumbar spine, is aching and sharp in character, radiates to the left buttock and posterior thigh, but not below the knee. Pain increased by: sitting for prolonged periods, bending forward, and twisting. Pain decreased by: lying down, applying heat, and gentle walking. Review of Systems: - Bowel & Bladder: No changes or abnormalities noted. - Numbness: Left buttock and posterior thigh, intermittent, started with the pain, relieved by lying down. - Weakness: No subjective weakness reported. - P&N's: Intermittent pins and needles in the left posterior thigh, particularly after sitting, resolves with movement. - SOB (shortness of breath): None reported. - Headaches: Occasional tension headaches, not related to current issue. - Dizziness: None reported. History of Present Illness: Patient’s history related to current issue includes a similar episode two years ago after gardening, which resolved with rest and over-the-counter pain medication within 2 weeks. The current episode is more severe. First episode: Two years prior, presented as dull low back ache. At its worst: Current pain is rated 7/10 at its worst, significantly impacting ability to sit at desk job and perform household chores. Stressors: Moderate work-related stress due to project deadlines. Family situation: Lives with partner and two school-aged children, partner provides good support. Past Medical and Surgical History: Previous treatments: Saw a physiotherapist for the prior episode, found some relief. No previous chiropractic care. No previous diagnoses related to current issue. Scan/MRI/X-ray results: None performed for current issue. No pregnancy history (male patient). Lifestyle Factors: Working conditions: Primarily seated desk job, approximately 8 hours a day, occasional heavy lifting (up to 15kg) at home. Activity limitations: Unable to comfortably sit for more than 30 minutes, difficulty bending to tie shoes, unable to play football with children. Current Medications: Paracetamol 500mg, 2 tablets every 6 hours as needed for pain. Ibuprofen 200mg, 1 tablet twice daily as needed. Family History: Mother has osteoarthritis in her knees. Father had occasional lower back pain. Red Flags: No unexplained weight loss, fever, trauma (other than lifting event), history of cancer, neurological symptoms, night sweats, or DVT history reported. The Why – Goal of Care: Patient’s stated goals for care include being able to sit comfortably at work, return to playing football with his children without pain, and improve overall flexibility to prevent future episodes. Objective: Assessment of Neurological Function: Reflexes: Patellar and Achilles reflexes 2+ bilaterally. Sensory testing: Intact to light touch in L4, L5, S1 dermatomes bilaterally. Dermatomes: No sensory deficits noted. Motor strength: Hip flexion, knee extension, ankle dorsiflexion, plantarflexion 5/5 bilaterally. Coordination: Intact. Dizziness or balance impairments: None. Vitals: Blood pressure: 128/82 mmHg. Heart rate: 75 bpm. Respiratory rate: 16 breaths/min. Temperature: 36.8 °C. Physical Examination Findings: General movement: Guarded lumbar spine flexion and rotation. Posture: Mild hyperlordosis in lumbar spine, shoulders slightly protracted. Specific SFMA-based or chiropractic functional assessments: - Cx flexion: Full ROM - Cx extension: Full ROM - Cx rotation L: Full ROM - Cx rotation R: Full ROM - GH pattern 1 (IntRot, extension) L: Good mobility - GH pattern 1 (IntRot, extension) R: Good mobility - GH pattern 2 (ExtRot, flexion) L: Good mobility - GH pattern 2 (ExtRot, flexion) R: Good mobility - MS flexion: Limited and painful (thoracolumbar junction) - MS extension: Limited and painful (thoracolumbar junction) - MS rotation L: Limited with pain - MS rotation R: Limited with pain - Single leg balance L: Stable for >30s - Single leg balance R: Stable for >30s - Deep squat: Restricted lumbar flexion at end range, compensatory hip external rotation. - Gait analysis: Antalgic gait, slight hesitation on heel strike, reduced arm swing. Results of Diagnostic Tests: No diagnostic tests reviewed at this time. Initial Thoughts, Diagnosis, and Plan: Initial Thoughts: Patient presents with acute lumbar facet syndrome and associated sacroiliac joint dysfunction, likely exacerbated by sedentary work and heavy lifting. Functional diagnosis is restricted segmental mobility in the lumbar spine (L4/L5, L5/S1) and left SI joint. Areas identified for chiropractic adjustment or mobilisation: Lumbar spine (L4/L5, L5/S1) and left sacroiliac joint. Patient Expectations: Patient expects significant pain reduction within a few visits and believes chiropractic care can help him avoid future similar episodes. He hopes to be back to normal within 4-6 weeks. Detailed Treatment Plan: Proposed management includes diversified chiropractic adjustments to the lumbar spine and left SI joint, soft tissue release to erector spinae and gluteal muscles, and specific exercise rehabilitation targeting core stability and hip mobility. Emphasis on team effort and rehab consistency. Frequency and Duration of Treatment: Suggested treatment frequency is 3 times per week for the first 2 weeks, then tapering to twice a week for 2-3 weeks, followed by once a week as symptoms improve. Planned duration is approximately 6-8 weeks, with periodic re-evaluation. Goals of Treatment: Short-term goals: Reduce pain to <3/10, improve sitting tolerance to 60 minutes, and restore pain-free bending. Long-term goals: Return to playing football, prevent future episodes, and improve overall spinal health. Self-care Recommendations: Home exercises: Cat-cow stretch, pelvic tilts, gentle lumbar rotations. Posture changes: Advised on ergonomic setup for desk job, regular movement breaks. Sleep advice: Recommended sleeping on side with pillow between knees or on back with pillow under knees. Load management instructions: Education on proper lifting mechanics and avoiding prolonged static postures. Referrals: Considering referral for imaging (X-ray) if no significant improvement after 2 weeks of care, or if new red flags emerge. Intervention / Actions: Treatment Provided: Diversified adjustments to L4/L5, L5/S1, and left SI joint. Myofascial release to lumbar paraspinals and left gluteal muscles. Details of Interventions: Supine diversified adjustment to L5/S1 (left side). Side posture adjustment to L4/L5 (left side). Supine drop-piece adjustment for left SI joint. Deep tissue massage to left gluteus medius and piriformis. Patient Response to Treatment: Patient reported immediate reduction in sharp pain by approximately 30% after adjustments. Noted increased ease of movement in lumbar flexion and rotation, though still some residual stiffness. Patient Education: Information shared on ergonomics for his desk job, importance of consistent home exercises, realistic recovery expectations for acute low back pain, and strategies for preventive care including regular exercise and proper lifting techniques. Family and Social Information: Discussed the importance of partner's support in encouraging home exercises and activity modification. Upcoming Events: Patient mentioned a family holiday in 3 weeks, aiming for significant improvement by then. Referral Path: Referred by a friend, "Dr. Thomas Kelly", who is also a patient at the clinic. Clothing Instructions: Advised to wear loose, comfortable clothing for future visits to facilitate examination and treatment. Follow-up and Continued Care: Next session scheduled for 1 November 2024 at 10:00 AM. Plan to re-evaluate symptoms and continue with adjustments and soft tissue work, progressively introducing more advanced exercises. Patient Concerns and Preferences: Patient expressed concern about the pain returning and preferred gentle adjustment techniques, which were accommodated. No specific contraindications or sensitivities noted. Alterations to Plan: Initially, planned for a more aggressive treatment approach, but scaled back slightly based on patient's preference for gentle techniques and his acute presentation. Focus for Next Appointment: Primary focus will be on further reducing lumbar pain, improving range of motion, and initiating core strengthening exercises. Internal Referrals: Considering internal referral to the clinic's biokineticist for more structured exercise rehabilitation once acute pain has settled.