Osteopathic Return Visit

Subjective: - Patient reports a return of lower back pain, described as a dull ache, with onset approximately 3 days ago. The pain is rated as a 5/10 in intensity. - The patient reports that the pain is aggravated by prolonged sitting and bending, and is relieved by rest and lying down. - Review of systems is negative for any other related symptoms. - Past medical history is significant for a previous lower back strain 2 years ago. No surgeries or chronic conditions. - Patient works as a desk clerk and reports a sedentary lifestyle. Exercises occasionally. - Current medications: Ibuprofen as needed for pain. - Social history: Patient lives alone, has a good support system, and reports no mental health concerns. - No known allergies. Assessment/ Findings: - Vitals: Blood Pressure 120/80, Heart Rate 72 bpm, Respiratory Rate 16, Temperature 37°C. - Physical examination reveals tenderness to palpation in the lumbar region, with restricted movement on flexion. Posture appears normal. Gait is normal. - No neurological deficits noted. - No diagnostic tests ordered or reviewed. Working Diagnosis: - Recurrent lumbar strain with associated somatic dysfunction. - Key areas for treatment include the lumbar spine and surrounding musculature. Plan: - Soft tissue techniques to address muscle tension and spasm. - Spinal mobilisation to improve joint mobility. - Frequency: Twice a week for the next two weeks. - Short-term goal: Reduce pain to 2/10. Long-term goal: Improve spinal mobility and return to normal activities. - Advice on ergonomic adjustments at work and home exercises. - No additional diagnostics or referrals planned at this time. Treatment/ Treatment response: - Soft tissue massage to the lumbar paraspinal muscles. Spinal mobilisation techniques applied to L4-L5. - Patient reported immediate relief of pain, rating it as 3/10 post-treatment. Additional Notes: - Provided education on proper posture and lifting techniques. - Instructed patient to perform core strengthening exercises daily. - Patient expressed concern about the impact of their job on their back pain.