Chief Complaint

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.