Subjective:
-Chief Complaint: Lower back pain, radiating to the right leg.
-Onset: Began approximately 2 weeks ago, following a weekend of heavy gardening.
-Duration: Constant ache, with intermittent sharp pains.
-Characteristics: Pain is described as a dull ache in the lower back, with sharp, shooting pains down the right leg. Aggravated by prolonged sitting and bending. Relieved by rest and lying down.
-History of Present Illness: Patient reports no previous episodes of back pain. Denies any recent trauma or injury. The patient reports that they have been taking over-the-counter ibuprofen, which provides minimal relief.
-Review of Systems: Reports no neurological symptoms such as numbness or tingling. No bowel or bladder dysfunction. No history of previous injuries or conditions affecting the musculoskeletal system.
-Past Medical History: No significant past medical history. No prior surgeries.
-Lifestyle Factors: Patient is a desk worker, spends a significant amount of time sitting. Exercises 3 times a week. Reports moderate stress levels.
-Current Medications: Ibuprofen 200mg as needed for pain.
-Family History: Father has a history of osteoarthritis.
Objective:
-Vitals: BP 130/80, HR 78, RR 16, Temp 37.0°C.
-Physical Examination: Posture analysis reveals a slight forward head posture and a mild lumbar scoliosis. Range of motion is limited in lumbar flexion and right lateral flexion. Muscle tone is increased in the lumbar paraspinal muscles. Palpation reveals tenderness over the L4-L5 and right SI joint. Straight leg raise test is positive on the right at 45 degrees.
-Neurological: Reflexes are 2+ and equal bilaterally. Sensory testing is intact. Motor strength is 5/5 in all extremities.
-Diagnostic Tests: No imaging studies performed at this visit.
Assessment:
-Diagnosis: Lumbar radiculopathy secondary to suspected disc herniation or facet joint dysfunction.
-Areas Requiring Adjustment: L4-L5, right SI joint.
Plan:
-Treatment Plan: Spinal manipulation to the lumbar spine and SI joint. Soft tissue therapy to the lumbar paraspinal muscles. Instruction in proper posture and body mechanics. Recommend ice application to the lower back for 20 minutes, 3 times a day.
-Frequency and Duration: 3 times per week for the next 2 weeks, followed by re-evaluation.
-Goals: Short-term: Reduce pain and improve range of motion. Long-term: Restore normal spinal function and prevent recurrence.
-Self-Care: Patient advised to avoid prolonged sitting and bending. Recommended to perform core strengthening exercises. Provided with a handout on proper lifting techniques.
-Referrals: No referrals at this time.
Consent:
-Discussion: The risks, benefits, and alternatives of chiropractic treatment were discussed with the patient. The patient understands the treatment plan and potential outcomes.
-Consent: Verbal consent was obtained.
-Questions: The patient had no further questions.
Interventions:
-Chiropractic Adjustments: Lumbar spine and SI joint adjustments performed using diversified technique. Soft tissue therapy performed to the lumbar paraspinal muscles.
-Response: Patient reported immediate relief of pain after the adjustment.
Evaluation:
-Progress: Patient reported a 30% reduction in pain after the first treatment.
-Modifications: Continue with the current treatment plan.
-Additional Notes: Patient was educated on the importance of maintaining good posture and proper body mechanics.
-Patient Education: Provided education on ergonomics, lifestyle modifications, and preventive measures.
-Follow-up: Schedule follow-up visit for 3 days from today, 4 November 2024.
Subjective:
-[Description of the current symptoms, including onset, duration, and characteristics of pain or discomfort (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Patient's history of the present illness or condition leading to the consultation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Review of systems pertinent to the chiropractic care, including any neurological symptoms, previous injuries, conditions affecting the musculoskeletal system, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Past medical and surgical history, especially related to spine, joints, and musculoskeletal health (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Lifestyle factors affecting health, such as exercise habits, occupational hazards, posture, sleep quality, stress levels, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Current medications, supplements, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Family history of musculoskeletal or spinal conditions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Objective:
-[Vitals including BP, HR, RR, Temperature, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Physical examination findings, including posture analysis, spinal alignment, range of motion in affected and adjacent areas, muscle tone and strength, palpation of spine and joints for tenderness or abnormalities, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Assessment of neurological function, if indicated, including reflexes, sensory testing, and motor strength, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Results of any diagnostic tests performed or reviewed, including imaging studies, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Assessment:
-[Chiropractic diagnosis or functional assessment based on the subjective and objective findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Identification of areas requiring adjustment or manipulation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Plan:
-[Detailed treatment plan, including specific adjustments, manipulation techniques to be used, and any adjunctive therapies (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Frequency and duration of the treatment plan (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Goals of treatment, both short-term and long-term (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Self-care recommendations or home exercises prescribed to the patient (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Mention any referrals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Consent:
-[Discussion of the risks, benefits, and alternatives of chiropractic treatment (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Patient's verbal or written consent obtained before proceeding with care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Any questions or concerns addressed before treatment (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Interventions:
-[Details of chiropractic adjustments and other therapeutic interventions performed during the visit (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Patient's response to treatment and any immediate improvements or adverse reactions observed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Evaluation:
-[Evaluation of patient progress towards treatment goals (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Modifications to the treatment plan based on patient progress and response (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Additional Notes: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Patient education provided on ergonomics, lifestyle modifications, and preventive measures (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
-[Plans for follow-up visits and continued care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
