SOAPIER

Subjective: - The patient, a 45-year-old male, presented with lower back pain persisting for the past two weeks, exacerbated by prolonged sitting and bending. He reports a history of lumbar disc herniation two years ago. - Past medical history includes hypertension and a lumbar discectomy performed in 2021. - Current medications include Lisinopril 10 mg daily and Ibuprofen 400 mg as needed for pain. - The patient is a non-smoker, consumes alcohol occasionally, and works as an office manager. - No known drug allergies. Objective: - Vital signs: Blood pressure 130/85 mmHg, heart rate 72 bpm. - Physical examination reveals tenderness in the lumbar region with limited range of motion in forward flexion. - Recent MRI shows mild disc bulge at L4-L5 without significant nerve root compression. Assessment: - Diagnosis: Acute exacerbation of chronic lower back pain secondary to lumbar disc bulge. - Clinical impression: The patient's symptoms are consistent with mechanical back pain. Plan: - Initiate a physical therapy regimen focusing on core strengthening and flexibility exercises. - Prescribe a short course of muscle relaxants (Cyclobenzaprine 5 mg at bedtime) for one week. - Educate the patient on proper ergonomics and posture during work. - Schedule a follow-up appointment in two weeks to assess progress. Intervention: - Performed manual therapy techniques including soft tissue mobilization and lumbar traction. Evaluation: - The patient reported immediate relief in muscle tension post-intervention. - Progress towards treatment goals will be evaluated in the next session. Review: - The patient is to return for a follow-up visit in two weeks.