Patient Consent
Consent to Treatment and Information Sharing:
Consent given
Subjective Assessment:
Presenting Complaint: Lower back pain, radiating into the left leg.
History of Present Condition: Pain started 2 weeks ago after lifting a heavy box. Aggravating factors include prolonged sitting and bending. Easing factors include rest and lying down.
Pain Scale: 6/10 at worst, 3/10 at best.
Functional Impact: Difficulty with work (sitting at a desk), ADLs (putting on socks), and sports (unable to play football).
Red Flags Screening: No red flags identified.
Past Medical History: No relevant history.
Medications: Ibuprofen 400mg as needed.
Goals of Treatment: To reduce pain to 2/10 within 4 weeks, return to work duties, and be able to walk for 30 minutes without pain.
Objective Assessment:
Observation/Posture: Forward head posture, slight lateral shift to the right.
Active and Passive ROM: Lumbar flexion limited to 60 degrees, pain with left lateral flexion.
Strength Testing: Weakness noted in left hamstring (4/5).
Pain on Palpation: Tenderness over L4/L5 and left paraspinal muscles.
Special Tests: Positive Slump test on the left.
Neurological Screen: Sensation intact, reflexes 2+ bilaterally.
Functional Movement Tests: Pain with single leg stance on the left.
Analysis:
Analysis and Reasoning: Suspect lumbar discogenic pain with radicular symptoms. Possible nerve root irritation.
Plan and Intervention:
Education Provided: Advice on posture, body mechanics, and pain management strategies.
Intervention(s) Commenced: Manual therapy to lumbar spine and soft tissue release to paraspinal muscles. Exercises: nerve glides and core stability exercises. 30 minutes.
Home Exercise Programme: Nerve glides, core stability exercises, and postural correction exercises.
Referral Required: No referral required at this time.
Next Appointment Booked: Yes
Patient Consent
Consent to Treatment and Information Sharing:
[Consent given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective Assessment:
Presenting Complaint: [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of Present Condition: [duration, aggravating/easing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pain Scale: [0-10] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Functional Impact: [work, ADLs, sports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Red Flags Screening: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History: [relevant history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medications: [list medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Goals of Treatment: [SMART goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective Assessment:
Observation/Posture: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Active and Passive ROM: [joint specific] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Strength Testing: [MMT or Functional Strength] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Pain on Palpation: [add body chart] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Special Tests: [relevant to region] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological Screen: [if indicated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Functional Movement Tests: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Analysis:
Analysis and Reasoning: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan and Intervention:
Education Provided: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Intervention(s) Commenced: [include intensity, duration etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Home Exercise Programme: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Referral Required: [if appropriate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Next Appointment Booked:
[Yes/No] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)