Consent: Verbal consent obtained for assessment and treatment.
Acupuncture checklist: Not applicable.
Diagnosis: Lumbar radiculopathy.
Subjective:
- Patient presents today with lower back pain radiating into the left leg.
- The pain started three weeks ago, is constant, and is located in the lower back and left leg. The pain is described as a sharp, shooting pain, rated as 7/10 in severity. It is worse with prolonged sitting and standing, and improves with rest and lying down.
- The patient reports that over-the-counter pain relievers provide minimal relief. Heat packs offer some comfort.
- The symptoms have gradually worsened over the past three weeks.
- No previous episodes of similar symptoms.
- The pain is significantly impacting the patient's ability to work and participate in recreational activities.
- Associated symptoms include numbness and tingling in the left foot.
Past Medical History:
- No significant past medical history.
- The patient is a non-smoker and drinks alcohol occasionally.
- No family history of back pain or neurological conditions.
- No known exposures.
- Immunization status up to date.
- Other: Patient denies any recent injuries or falls.
Objective:
- Vitals signs: Not assessed.
- Physical or mental state examination findings, including system specific examination(s): Lumbar spine examination revealed reduced range of motion in flexion and lateral flexion. Positive straight leg raise test at 45 degrees on the left. Neurological examination showed decreased sensation in the L5 dermatome and reduced reflexes at the left ankle.
- Investigations with results: Not applicable.
Assessment:
- Likely diagnosis: Lumbar radiculopathy.
- Differential diagnosis: Lumbar sprain/strain, disc herniation.
Plan:
- Investigations planned: MRI lumbar spine.
- Treatment planned: Physiotherapy including manual therapy, exercises for core strengthening and flexibility, and education on posture and body mechanics. Recommend a course of 6 sessions.
- Relevant other actions such as counselling, referrals etc: Advised patient to avoid activities that exacerbate symptoms. Referred to GP for consideration of medication for pain management.
Consent: [Alway note verbal consent to assessment and treatment]
Acupuncture checklist: [VCG and answers to: uncontrolled epilepsy or diabetes, recent infective skin or heart conditions, pregnancy, allergic to metals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Diagnosis: [Likely diagnosis following on from initial assessment (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Subjective:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention 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 leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention 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 leave blank)
- [Mention 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 leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Past Medical History:
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Assessment:
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(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 include in your note.)
