Chiropractor's note

Subjective: - The patient reports experiencing sharp lower back pain that began two weeks ago after lifting a heavy object. The pain radiates down the right leg and is aggravated by sitting and bending. - The patient has a history of chronic lower back pain due to a herniated disc diagnosed two years ago. - The patient denies any neurological symptoms but reports occasional numbness in the right foot. - Past medical history includes a lumbar discectomy performed last year. - The patient works as a warehouse manager, which involves heavy lifting and prolonged standing. The patient exercises occasionally but reports poor sleep quality and high stress levels. - Current medications include ibuprofen 400 mg as needed for pain. - Family history is significant for osteoarthritis in the patient's mother. Objective: - Vitals: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temperature 36.8°C. - Physical examination reveals poor posture with anterior pelvic tilt, limited range of motion in lumbar flexion and extension, and tenderness upon palpation of the L4-L5 region. - Neurological assessment shows normal reflexes and motor strength, but decreased sensation in the right foot. - Reviewed MRI results showing a herniated disc at L4-L5. Assessment: - Diagnosis: Lumbar disc herniation with radiculopathy. - Areas requiring adjustment: L4-L5 vertebrae. - Diagnosis codes: M51.26 (lumbar disc displacement), M54.16 (radiculopathy, lumbar region). Plan: - Treatment plan includes spinal adjustments at L4-L5, soft tissue therapy, and therapeutic exercises focusing on core strengthening. - Frequency: Twice a week for four weeks. - Goals: Short-term - pain relief and improved range of motion; Long-term - enhanced posture and functional mobility. - Prescribed home exercises include pelvic tilts and hamstring stretches. - Referral to a physical therapist for additional rehabilitation. Interventions: - Performed spinal adjustments at L4-L5 and soft tissue therapy on the lumbar region. - The patient reported immediate relief in pain intensity post-treatment. Evaluation: - The patient shows progress towards short-term goals with reduced pain and improved mobility. - Plan to continue current treatment regimen and reassess in two weeks. Additional Notes: - Educated the patient on proper lifting techniques and ergonomic adjustments at work. - Scheduled follow-up visit in one week to monitor progress. - The patient expressed a preference for non-surgical interventions.