EP Initial Assessment Note

Referral type: Medicare, Total number of sessions: 10, Current number of sessions: 1. Reason of referral: The patient was referred for management of chronic lower back pain. The expectation is to improve mobility and reduce pain levels. The complaint has been progressing over the last 6 months with increased stiffness in the morning. Aggravators: - Prolonged sitting - Lifting heavy objects Relievers: - Heat therapy - Gentle stretching Subjective: Medical History: - Hypertension - Type 2 Diabetes Musculoskeletal: - L4-L5 disc herniation diagnosed in 2021, currently managed with physiotherapy and pain medication. Medications: - Metformin 500mg BID - Amlodipine 5mg QD Social History: - Lives with spouse and two children - Works full-time as an accountant - Non-smoker, occasional alcohol use (1-2 drinks per week) Exercise History: Current: Walking 3 days per week, 30 minutes per session Previous: Gym workouts 2 days per week, 1-hour sessions Barriers: - Time constraints due to work Goals: - Increase walking to 5 days per week - Reduce pain levels by 50% in 3 months - Improve flexibility and strength in the lower back Objective: - Active range of motion: Limited flexion and extension in lumbar spine - Strength testing: Weakness in core muscles Treatment: - Pain education provided - Home Exercise Program: - Aerobic: Walking 4 days per week, 30 minutes - Resistance: 3 x 10 reps of squats, lunges, and core exercises Assessment: - The patient presents with chronic lower back pain likely due to L4-L5 disc herniation. Limited range of motion and core weakness are contributing factors. Plan: - Continue with the current exercise program, review in 2 weeks - Patient to maintain a daily exercise log - Referral to physiotherapist for additional manual therapy - Exercise plan: Aerobic 4 days per week, resistance training 3 days per week - Monitor progress and adjust plan as needed