MD Standard Ongoing Note

S/ - Client reports increased lower back pain after gardening, rating it a 6/10 on the pain scale. - Client reports consistent adherence to prescribed core strengthening exercises, performing them 3 times per week. - Client reports that time constraints are a barrier to exercise participation. - Symptoms impact daily activities, making it difficult to lift groceries. - No new medical updates. Client’s goal is to reduce back pain and improve functional capacity. O/ - Client demonstrated good form during the plank exercise, with slight lumbar arching noted. - Heart rate increased to 110 bpm during the exercise session, RPE of 4/10, no reported pain or fatigue. - Completed the Oswestry Disability Index (ODI) with a score of 24. - Blood pressure 130/80 mmHg, resting heart rate 70 bpm. - Client reported feeling a slight increase in back pain during the deadlift exercise. A/ Exercise Completed: - Core strengthening exercises: plank (3 sets of 30 seconds), bird dog (3 sets of 10 reps), deadlifts (3 sets of 8 reps) at 10kg, performed with good form. Assessment: 1. Lower Back Pain - Differential diagnosis: Lumbar strain, possible facet joint irritation. - Investigations planned: Review ODI scores at next visit. - Treatment planned: Continue core strengthening exercises, education on proper lifting techniques, and discuss pain management strategies. - Relevant referrals: None. 2. Reduced Functional Capacity - Differential diagnosis: Deconditioning due to pain. - Investigations planned: Repeat ODI and functional testing in 2 weeks. - Treatment planned: Progress exercise intensity and duration, encourage regular activity. - Relevant referrals: None. Education Provided: - Provided advice on proper lifting techniques and posture. - Discussed pacing strategies and the importance of rest. P/ Follow-Up: - Next session scheduled for 15 November 2024, in-person. - Reassess ODI and functional capacity at the next visit. - No referrals needed. Monitoring and Safety: - Monitor for increased pain, numbness, or weakness. Stop exercise if symptoms worsen. - Report any significant changes in symptoms before the next visit. Program/ADL Recommendations: - Continue core strengthening exercises, focusing on proper form. - Encourage regular walking and light activity. - Discussed strategies for managing pain and fatigue. Other Notes: - Client is motivated to improve and is compliant with recommendations.