Physiotherapy Initial Assessment
Current Condition/Complaint:
- The patient presents with a sharp, localised pain in the lower back, specifically in the lumbar region. The pain is exacerbated by prolonged sitting, bending, and twisting motions. The pain radiates down the left leg to the knee, but not below.
- Onset was approximately 2 weeks ago, following a heavy lifting incident at work.
- The injury occurred while lifting a heavy box at work. The patient felt a sudden sharp pain in their lower back.
- The patient has not had any prior therapy or surgery for this condition.
- The patient has not seen any other health professionals for this condition.
- The pain has gradually worsened over the past two weeks. Initially, it was a dull ache, but it has intensified and now includes radiating pain.
- The pain is worsened by prolonged sitting and bending. It is slightly relieved by rest and lying down.
- The symptoms have progressively worsened since the onset. The patient reports increasing difficulty with daily activities.
- The patient has not experienced similar symptoms in the past.
- The symptoms significantly impact the patient's ability to work, as their job involves heavy lifting and prolonged standing. They also have difficulty with household chores and recreational activities.
- Associated symptoms include muscle spasms in the lower back and occasional numbness in the left leg.
Investigations:
- X-rays of the lumbar spine were taken and showed mild degenerative changes, but no acute fractures.
Medical History:
- The patient has a history of hypertension, well-controlled with medication.
- No previous surgeries.
- No known allergies.
- The patient is currently taking medication for hypertension (Lisinopril 10mg daily).
- No relevant family medical history.
Social History:
- The patient is a smoker (10 cigarettes per day) and consumes alcohol occasionally.
- The patient is employed as a warehouse worker, which involves heavy lifting.
- The patient reports a low level of physical activity outside of work.
- The patient reports feeling anxious about their condition and its impact on their ability to work.
Patient Goals:
- Short-term physiotherapy goals: Reduce pain levels to a manageable level within 2 weeks, improve mobility, and be able to sit for 30 minutes without pain.
- Long-term physiotherapy goals: Return to full work duties within 6 weeks, improve core strength, and prevent future episodes.
Objective:
- Physical examination revealed limited lumbar flexion and extension, with pain at the end range of motion. Positive straight leg raise test at 45 degrees on the left side. Palpation revealed tenderness over the lumbar paraspinal muscles.
- Measurements: Lumbar flexion: 30 degrees (normal 60 degrees). Lumbar extension: 10 degrees (normal 30 degrees). Straight leg raise: 45 degrees on the left.
- Assessment findings: Muscle spasm, reduced range of motion, and pain with specific movements.
Diagnosis/Impression:
- Likely diagnosis: Lumbar strain with possible radicular symptoms.
- Differential diagnosis: Disc herniation, facet joint dysfunction.
Treatment:
- Education: Provided education on proper posture, body mechanics, and pain management strategies.
- Hands-on treatment: Soft tissue mobilisation to lumbar paraspinal muscles, and gentle lumbar mobilisations.
- Active therapy: Core stabilisation exercises, and range of motion exercises.
- Home exercise program (HEP): Instructions for performing core stabilisation exercises (e.g., pelvic tilts, abdominal bracing) 3 times a day, 10 repetitions each.
Assessment:
- The patient presents with a lumbar strain and associated radicular symptoms. The patient's pain levels are high, and their range of motion is limited. The patient is motivated to improve.
- Prioritized problems list: Pain, limited range of motion, muscle spasm, and functional limitations.
- Progress towards stated goals: The patient has shown some improvement in pain levels and mobility since the initial assessment.
- Factors affecting progress and any need for modification in the plan: The patient's smoking habit may be affecting their healing process. The treatment plan may need to be modified if the patient's pain does not improve.
Plan:
- Detailed treatment plan: Continue with soft tissue mobilisation, lumbar mobilisations, and core stabilisation exercises. Progress exercises as tolerated. Schedule follow-up sessions twice a week for the next 2 weeks.
- Anticipated goals and expected outcomes: Reduce pain levels, improve range of motion, and improve functional abilities.
- Referrals to other professionals: Consider referral to a pain management specialist if pain is not controlled.
Current Condition/Complaint:
- [Detailed description of primary injury, problem, complaint, or symptom] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Date of onset and/or date of surgery] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Description of how the injury occurred or complaint began] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Details of any prior therapy, interventions, and/or surgery] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Details of specialists and/or other health professionals involved in treatment to date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Describe progression of complaint and nature of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [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 omit completely.)
- [Progression: describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Previous episodes: 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 omit completely.)
- [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 omit completely.)
- [Associated symptoms: any other symptoms (focal and systemic) that accompany the reasons for visit and chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Investigations:
- [Completed investigations with results] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. Do not include planned or ordered investigations; those should appear in the Management Plan section. Omit completely if not mentioned.)
Medical History:
- [List existing and past medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Details of previous surgeries/treatments] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention any allergies] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention current medications including over-the-counter or herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention family medical history of disease that may impact therapy] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Social History:
- [Mention relevant social history like lifestyle factors, including tobacco and alcohol use, that may affect therapy] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Employment status, physical demands of job, work-related activities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [General exercise and activity levels] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mental health and emotional state] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Patient Goals:
- [Short-term physiotherapy goals and time frame for achieving these goals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Long-term physiotherapy goals and time frame for achieving these goals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Objective:
- [Physical examination details] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Observations, tests, and measurements by the therapist] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Specific measurements and assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnosis/Impression:
- [Likely diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Treatment:
- [List all educational treatment that was provided throughout the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. Only include treatments administered within this session. Do not include past or planned treatments.)
- [List all hands-on treatment provided throughout the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. Only include treatments administered within this session. Do not include past or planned treatments.)
- [List all active therapy treatment provided throughout the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note. Only include treatments administered within this session. Do not include past or planned treatments.)
- [List home exercise program (HEP) provided, including details like reps, sets and frequency] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Assessment:
- [Therapist's professional opinion based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Prioritized problems list] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Progress towards stated goals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Factors affecting progress and any need for modification in the plan] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Plan:
- [Detailed treatment plan including interventions, frequency, and duration] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Anticipated goals and expected outcomes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Referrals to other professionals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(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 section blank. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
