Chiropractic Visit Template

Subjective: - Patient reports acute low back pain radiating into the left gluteal region, which started approximately three days ago after lifting a heavy box. The pain is described as a dull ache with intermittent sharp stabs, rated 7/10 at its worst. It is exacerbated by bending, sitting for prolonged periods, and improves slightly with rest. - The current episode of low back pain began suddenly while moving furniture. Patient experienced an immediate sharp pain, followed by a persistent ache. This is the first significant episode of low back pain this year, though they have had occasional mild stiffness in the past. - Patient denies any neurological symptoms such as numbness, tingling, or weakness in the lower extremities. No history of major trauma or previous spinal surgeries. Denies any fever, chills, or unexplained weight loss. No previous injuries requiring chiropractic or medical intervention in the lumbar spine. - Past medical and surgical history particularly relating to the spine, joints and musculoskeletal health: - Childhood ankle sprain (right, age 10) - Appendectomy (age 25) - Patient works as an office administrator, spending 8 hours a day seated at a desk. Reports infrequent exercise, typically a 20-minute walk twice a week. Posture is self-described as "slouched" when sitting. Reports difficulty sleeping due to pain, averaging 5-6 hours of interrupted sleep per night. High stress levels reported due to work deadlines. - Current medications and supplements: - Ibuprofen 400mg, as needed for pain (takes 2-3 times daily) - Multivitamin, daily - No family history of specific musculoskeletal or spinal conditions mentioned, parents both report occasional age-related stiffness. Objective: - Vital signs including blood pressure, heart rate, respiratory rate and temperature: - BP: 128/82 mmHg - HR: 78 bpm - RR: 16 breaths/min - Temp: 36.8°C - Physical examination revealed a forward head posture and mild lumbar hyperlordosis. Range of motion in the lumbar spine was limited and painful with flexion (30% reduced) and left lateral flexion (40% reduced). Muscle tone was increased in the lumbar paraspinals bilaterally, with tenderness upon palpation at L4-L5 and L5-S1. No significant muscle atrophy observed. Tenderness and restricted movement noted in the sacroiliac joint on the left. - Neurological function assessment showed intact reflexes (patellar, Achilles) bilaterally, full motor strength (5/5) in bilateral lower extremities, and intact sensation to light touch in L2-S1 dermatomes. No signs of radiculopathy. - No diagnostic imaging performed or reviewed at this visit. Assessment: - Chiropractic diagnosis: Acute Lumbosacral Strain/Sprain with associated Sacroiliac Joint Dysfunction (Left). - Areas identified as requiring adjustment or manipulation: - Lumbar spine (L4, L5) - Sacroiliac joint (left) Plan: - Detailed treatment plan including specific adjustments, manipulation techniques and adjunctive therapies such as soft tissue therapy, therapeutic exercises or electrotherapy modalities: - Lumbar spine diversified adjustments (L4, L5) - Left sacroiliac joint mobilisation/manipulation - Soft tissue therapy to lumbar paraspinals and gluteal muscles - Instruction on core strengthening exercises (e.g., pelvic tilts, bird-dog) - Instruction on gentle lumbar stretches (e.g., cat-cow) - Recommended frequency and duration of the treatment plan: Three visits per week for two weeks, then re-evaluation. - Short-term and long-term treatment goals including pain relief, range of motion improvement, postural correction and functional improvements: - Short-term: Reduce pain to <3/10, improve lumbar flexion by 50%. - Long-term: Restore full pain-free range of motion, improve core stability, prevent recurrence of low back pain. - Self-care recommendations and home exercises prescribed to the patient: - Apply ice packs to the affected area for 15-20 minutes, 3-4 times daily. - Avoid prolonged sitting; take frequent breaks to stand and stretch. - Perform prescribed core strengthening and stretching exercises daily. - Maintain proper lifting mechanics (lift with legs, not back). - No referrals to other health professionals or services at this time. Consent: - Risks and benefits of chiropractic treatment, including potential for temporary soreness, discussed with the patient. Alternatives such as physical therapy and medication were also briefly mentioned. - Verbal consent obtained from the patient prior to commencing care. - Patient expressed concern about potential for increased pain after the first adjustment; assured that this is a normal, temporary response and encouraged to report any significant changes. Interventions: - Details of chiropractic adjustments and other therapeutic interventions performed during the visit: - Lumbar diversified adjustment performed at L4 and L5, achieving audible cavitation. - Left sacroiliac joint adjustment (side posture). - Manual release of left gluteus medius and lumbar paraspinals. - Instruction provided for home exercises. - Patient reported slight immediate reduction in pain (from 7/10 to 6/10) post-adjustment, with increased ease of movement in flexion. No adverse reactions observed. Evaluation: - Evaluation of patient progress towards treatment goals: Initial visit, baseline established. Patient responded positively to initial treatment with some pain reduction and improved mobility. - Modifications to the treatment plan based on patient progress and response: No modifications to the initial plan after the first visit. - Patient education provided on ergonomics, lifestyle modifications and preventive measures: Discussed proper sitting posture, safe lifting techniques, and the importance of regular, gentle movement. Emphasised hydration and anti-inflammatory diet principles. - Plans for follow-up visits and continued care: Follow-up visit scheduled for 1 November 2024 at 10:00 AM.