Chiropractic Initial Consultation

Verbally consented to the use of Heidi for note-taking. Referral source: - Google search - Dr. Emily Carter, GP History: Patient is a 35-year-old male presenting with lower back pain. He reports no smoking history and drinks alcohol socially. He works as a software engineer. Primary Complaint Lower back pain that started approximately 2 weeks ago. Secondary Complaints Neck stiffness. OPQRST: Onset - Symptoms began approximately 2 weeks ago after lifting a heavy box. Duration/Frequency - Pain is constant, rated 6/10, and worsens with prolonged sitting. Traumas or accidents: - Lifting a heavy box 2 weeks ago at work. Previous treatment: - Over-the-counter pain relievers, which provided minimal relief. Subjective Quality: - "It feels like a constant ache with sharp, shooting pains down my leg." Pain is rated as a 6/10 on a visual analogue scale. - Pain is worse when sitting for long periods and alleviated by walking around. - Associated symptoms: Tingling in the left leg. Goals and expectations: - Life Effect: The pain is affecting his ability to work and enjoy his hobbies. - The patient wants to return to his normal activities without pain. - Long term effect of this condition: The patient is concerned about the pain becoming chronic. - Goals and Expectations: Patient desires pain relief, improved mobility, and a return to normal activities. Subjective progression: - The condition has been worsening over the past week. Types of care: - Patient is seeking short-term acute management. Medical History: - No significant past medical or surgical history. - Family history of back pain in his father. - Social history: Non-smoker, social alcohol use. - Allergies: No known allergies. - Medications: Ibuprofen as needed. - Immunization history & status: Up to date. - Other relevant history or contributing factors: Sedentary lifestyle. Physical Examination: - Vital signs: Blood pressure 120/80, pulse 72 bpm, temperature 37°C. - Physical or mental state examination findings, including system specific examination(s): - Musculoskeletal: Lumbar paraspinal muscle spasm, decreased range of motion in lumbar spine, positive straight leg raise test on the left. - Neurological: Normal reflexes, sensation intact. - Orthopedic: Positive Kemp's test. - Chiropractic: Palpable tenderness at L4-L5. Investigations: - None completed at this time. Clinical Impression: - Likely diagnosis: Lumbar sprain/strain. - Differential diagnosis: Disc herniation. Management Plan: - Investigations planned: X-rays of the lumbar spine. - Treatment planned: Chiropractic adjustments, soft tissue therapy, and home exercises. - Relevant other actions, such as counseling, referrals, lifestyle recommendations, etc.: Advised on proper lifting techniques and ergonomics. Recommended a follow-up appointment in one week.