Subjective:
- The patient, a 45-year-old male, presents with lower back pain that has persisted for the past two weeks. He reports the pain is exacerbated by prolonged sitting and alleviated by standing or walking. The patient has a history of lumbar strain and underwent a lumbar discectomy five years ago. He is currently taking ibuprofen as needed for pain relief. The patient works as a software engineer and spends long hours at a desk. He has no known allergies.
Objective:
- On examination, the patient exhibits a slightly hunched posture with limited range of motion in the lumbar spine. Palpation reveals tenderness in the lower lumbar region. Gait is normal. No recent diagnostic tests or imaging results are available.
Assessment:
- The clinical assessment suggests a recurrence of lumbar strain, likely due to prolonged sitting and poor ergonomic setup at work.
Plan:
- A chiropractic adjustment was performed using the Diversified Technique, focusing on the lumbar spine. The patient was advised to perform daily stretching exercises targeting the lower back and hamstrings. Ergonomic modifications at the workplace were recommended, including the use of a standing desk. The patient is scheduled for a follow-up visit in two weeks to monitor progress and reassess symptoms.
Subjective:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Objective:
- [describe physical examination findings, including posture, gait, range of motion, and any palpation findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any diagnostic tests or imaging results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Assessment:
- [provide a summary of the clinical assessment, including diagnosis or clinical impression] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Plan:
- [describe the chiropractic adjustment performed, including specific techniques used] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [mention any additional treatments or therapies recommended, such as exercises, stretches, or lifestyle modifications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [outline follow-up plan, including next visit and any monitoring or reassessment plans] (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 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.)