Primary Complaint:
Patient presents with lower back pain, described as a dull ache, radiating into the left buttock. The pain is exacerbated by prolonged sitting and bending. The patient reports the pain has been present for approximately four weeks.
Secondary Complaint:
Patient reports occasional headaches, primarily located in the occipital region, occurring approximately twice per week. These headaches are not associated with any specific activities.
Date/ Mode of Onset:
The lower back pain began approximately four weeks ago, following a weekend of heavy gardening. The patient recalls feeling a sudden strain while lifting a heavy bag of soil.
Course:
The lower back pain initially presented as a mild ache, gradually worsening over the first week. The pain has remained relatively consistent since then, with occasional flares after periods of increased activity. The headaches have been present for several months, with no significant change in frequency or intensity.
Type of Pain / Severity:
The lower back pain is described as a dull ache, rated as a 5/10 on the pain scale. The pain radiates into the left buttock. The headaches are described as a pressure-like sensation, rated as a 3/10 on the pain scale.
Frequency / Duration:
The lower back pain is present most of the day, with exacerbations during prolonged sitting or bending. The headaches occur approximately twice per week, lasting for several hours.
Previous Episodes:
The patient reports a similar episode of lower back pain approximately two years ago, which resolved with rest and over-the-counter pain medication.
Aggravating Factors:
Prolonged sitting, bending, and lifting heavy objects aggravate the lower back pain. The headaches are not associated with any specific triggers.
Relieving Factors:
Rest and over-the-counter pain medication provide some relief from the lower back pain. The patient has not identified any specific relieving factors for the headaches.
Sleep / Night Sweats / Diet:
The patient reports sleeping approximately 7-8 hours per night. No night sweats are reported. The patient's diet is generally healthy, with no significant changes related to the symptoms.
Previous Treatment (X-rays, MRI, CAT scan, Urine, Bloods, Biopsy, GP DX, Specialist DX):
The patient has not sought any previous medical treatment for the current episode of lower back pain. The patient reports seeing their GP for the headaches, who advised them to take over the counter pain relief.
Associated Symptoms:
No associated symptoms are reported.
General Past History of Trauma either macrotrauma or repeated microtrauma; accidents, Fractures, Disease, surgeries, allergies, pregnancies, other medical history, Spinal History of strain: The patient reports no history of trauma, fractures, diseases, surgeries, allergies, or pregnancies. The patient works as a desk based office worker and sits for prolonged periods.
(Health Aim/ goals) If we could change anything about your health that would have the biggest impact on your quality of life not just now but also in five years time - what would they be. What would be the 1, 2, 3 goals?
The patient's primary goal is to eliminate their lower back pain and headaches. They also aim to improve their posture and overall spinal health to prevent future episodes.
On a scale of 0-10 how motivated are you to truly fix this problem without drugs or surgery? Why isn't it lower?
The patient rates their motivation level as an 8/10. They are motivated to seek chiropractic care to avoid relying on medication and to address the underlying cause of their pain.
Do you have any obstacles that will prevent you from getting care in our centre such as time, transportation, travel a lot.
The patient has no obstacles to receiving care at the centre.
Primary Complaint:
[document the patient's primary complaint, including location, duration, and any recent developments of symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Psecondary Complaint:
[document the patient's additional complaints that are not covered under primary complaint, including location, duration, and any recent developments of symptoms] (Only include if explicitly mentioned in addition to primary complaint transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Date/ Mode of Onset:
[describe the date and mode of onset of the patient's symptoms, including activities or events leading to onset and initial presentation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Course:
[detail the progression and current nature of the patient's symptoms since onset, including their persistence and any new characteristics or progression of symptoms over time] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Type of Pain / Severity:
[describe the characteristics of the patient's pain, including its type and severity in specific regions and any referral (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Frequency / Duration:
[document the frequency and duration of the patient's symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Previous Episodes:
[detail any previous episodes of similar symptoms, including their nature, typical resolution, and differences from the current episode] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Aggravating Factors:
[identify any factors that aggravate the patient's symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Relieving Factors:
[identify any factors that relieve the patient's symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Sleep / Night Sweats / Diet:
[document any changes in sleep patterns, number of hours sleep per night, sleeping posture, presence of night sweats, or dietary changes related to the symptoms, and general sleep quality] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Previous Treatment (X-rays, MRI, CAT scan, Urine, Bloods, Biopsy, GP DX, Specialist DX):
[detail any previous treatments, investigations (e.g., X-rays, MRI, CT scans, urine tests, blood tests, biopsies), and diagnoses from general practitioners or specialists] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Associated Symptoms:
[document any associated symptoms, specifically noting changes in bowel or bladder function, altered sensation in the saddle area, or other related complaints] (Only include if explicitly mentioned in transcript, context or clinical note, else include only the absence of associated symptoms or any signs of cord compression in this section entirely. Write in a single paragraph.)
General Past History of Trauma either macrotrauma or repeated microtrauma; accidents, Fractures, Disease, surgeries, allergies, pregnancies, other medical history, Spinal History of strain: [include information about possible sources of mechanical strain from long term sitting or strain from manual work, Exercise or Hobbies]
[document the patient's general past medical history, including any history of macro or micro trauma, fractures, diseases, surgeries, allergies, pregnancies, other relevant medical conditions, and spinal history related to strain from work, exercise, or hobbies] (Only include if explicitly mentioned in transcript, context or clinical note, else state “nothing of note related by patient” in this section. Write in a single paragraph.)
(Health Aim/ goals) If we could change anything about your health that would have the biggest impact on your quality of life not just now but also in five years time - what would they be. What would be the 1, 2, 3 goals?
[identify the patient's health aims and goals that would significantly impact their quality of life, both in the present and in five years] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
On a scale of 0-10 how motivated are you to truly fix this problem without drugs or surgery? Why isn't it lower?
[assess the patient's motivation level on a scale of 0-10 to resolve their problem without drugs or surgery, and document their reasoning for this motivation level] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
Do you have any obstacles that will prevent you from getting care in our centre such as time, transportation, travel a lot.
[identify any potential obstacles preventing the patient from receiving care, such as limitations related to time, transportation, or travel commitments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph.)
(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 included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
