Initial Osteopathic Consultation Note

Physiotherapist: Initial Osteopathic Consultation Note Patient Demographics: 45 years old, Female, Accountant (sedentary, prolonged sitting), Avid gardener, enjoys hiking on weekends. Chief Complaint: Persistent lower back pain radiating down the left leg for the past 3 weeks. Pain Assessment (SOCRATES): Site: Lumbar spine (L4-L5 region) with radiation to the left gluteal region and posterior thigh. Onset: Pain started approximately 3 weeks ago after a long day of gardening, involving heavy lifting and bending. Gradually worsened over the first few days. Character: Dull ache in the lower back, sharp, shooting pain down the left leg. Radiation: Pain radiates from the left lower back, through the left gluteus, and down the posterior aspect of the left thigh, stopping above the knee. Associated Symptoms: Occasional tingling sensation in the left foot, mild muscle stiffness in the lower back in the mornings. No weakness reported. Timing: Constant dull ache, with intermittent sharp pains, especially when bending forward or standing for prolonged periods. Worse at the end of the day. Exacerbating Factors: Bending, lifting, prolonged sitting, prolonged standing, coughing, and sneezing. Relieving Factors: Lying down on her back with knees bent, applying heat pack to the lower back, walking short distances. Severity: On a scale of 0-10, the dull ache is typically 4-5/10, with sharp pains reaching 7-8/10. Accident History: No recent falls or specific traumatic accidents. Minor car accident 10 years ago with whiplash, fully recovered. Surgical History: Appendectomy, 1 November 2005. Other relevant medical history / medications: History of mild hypertension, well-controlled with Ramipril 5mg daily. No known allergies. Systems Screening: No significant cardiac, respiratory, gastrointestinal, or genitourinary symptoms. Neurological exam reveals no gross deficits in upper extremities, but lower extremity exam to follow. Differential Diagnosis: Lumbar disc herniation (L4-L5/L5-S1) with radiculopathy, Lumbar strain/sprain, Sciatica, Piriformis syndrome.