**Subjective:**
- Patient presents with complaints of lower back pain and radiating pain down the left leg.
- Pain started 2 weeks ago, constant ache with sharp, shooting pains. Located in the lumbar region, radiating down the posterior aspect of the left leg to the foot.
- Pain is worsened by prolonged sitting and bending. Relieved by lying down and using a lumbar support.
- Symptoms have gradually worsened over the past two weeks.
- No previous episodes of similar pain.
- Pain limits ability to sit for more than 30 minutes, affecting work and leisure activities.
- Associated symptoms include tingling and numbness in the left foot.
**Past Medical History:**
- Patient reports no significant past medical or surgical history.
- Patient is a non-smoker and drinks alcohol occasionally. Works as a desk-based office worker.
- Family history of back pain in father.
- No known exposure history.
- Immunization status up to date.
- No other relevant subjective information.
**Objective:**
- Vitals: BP 130/80, HR 78, RR 16, SpO2 98%.
- Physical examination reveals limited lumbar flexion and extension. Positive straight leg raise test on the left at 45 degrees. Reduced sensation in the L5 dermatome.
- No investigations with results.
**Treatment: **
- Patient performed lumbar stabilization exercises.
- Treatment modalities used: Manual therapy to the lumbar spine and soft tissue mobilization.
- Patient educated on proper posture and body mechanics. Advised to avoid prolonged sitting.
**Assessment:**
- Likely diagnosis: Lumbar radiculopathy secondary to disc herniation.
- Differential diagnosis: Spinal stenosis, facet joint syndrome.
- Analysis of movement patterns: Restricted lumbar range of motion, altered gait pattern.
**Plan:**
- Investigations planned: MRI lumbar spine.
- Treatment planned: Continue with manual therapy, exercises, and education.
- Referral to pain management clinic.
**Subjective:**
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
**Past Medical History:**
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
**Objective:**
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
**Treatment: **
- [Exercises performed (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment modalities used (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant education or advice given (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
**Assessment:**
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [ Analysis of movement patterns (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)}
**Plan:**
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
