Initial at WDC

WHAT DO YOU WANT TO ACHIEVE WITH YOUR HEALTH? I want to be able to walk my dog in the park without pain, and to be able to play with my grandchildren. It's important to me because I miss being active and I want to be able to enjoy my life to the fullest. WHAT ARE YOUR MOST IMPORTANT GOALS AND WHY? IF YOU COULD ACHIEVE THOSE GOALS, HOW WOULD IT MAKE YOU FEEL? "To be able to walk without pain and to be able to play with my grandchildren. It would make me feel happy and fulfilled." WHAT WOULD YOU LIKE YOUR BODY PAIN PART(S) TO LOOK LIKE IN 12 MONTHS? IS THERE ANYTHING ELSE YOU THINK I SHOULD KNOW ABOUT WHAT ACTIVITIES YOU HOPE TO GET BACK TO DOING ONCE YOU’VE MADE A FULL RECOVERY FROM YOUR [injury/pain]? WE ARE NOW GOING TO CHANGE GEARS. LET’S TALK ABOUT WHAT IS GOING ON WITH YOU RIGHT NOW. I WANT TO KNOW HOW THIS IS AFFECTING YOU. TELL ME EVERYTHING THAT’S GOING ON FOR YOU RIGHT NOW LOCATION & RADIATION OF SYMPTOMS "I would like my back pain to be gone. I hope to be able to go hiking again. The pain is in my lower back, radiating down my left leg. It's a sharp, shooting pain." WHAT’S THE IMPACT THAT THAT IS HAVING FOR YOU? HOW MANY PILLOWS DO YOU SLEEP WITH UNDER YOUR HEAD? AND WHAT ARE THEY MADE OF? OBSERVATION I am unable to sleep well, and it is affecting my mood and ability to work. I sleep with one feather pillow. [Posture, foot arches] Patient presents with a slight forward head posture and mild pronation of the left foot. WEIGHT BEARING SYMMETRY - WEIGHING SCALES FUNCTIONAL TESTS - E.G. - GAIT, SQUAT, LUNGE, SIT TO STAND, BALANCE [Gait pattern, squatting, single leg stance, lunging] Gait: Antalgic gait pattern. Squat: Limited depth due to pain. Single leg stance: Unable to maintain balance on left leg for more than 2 seconds. Lunging: Pain in lower back. MOVEMENT TESTING [active range of motions] Lumbar flexion: Limited to 45 degrees, pain at end range. Lumbar extension: Limited to 10 degrees, pain at end range. Lateral flexion: Limited to 20 degrees to the left, 30 degrees to the right, pain on the left side. NEURO TESTING (DERM, MYO, REFLEXES) (WHEN RELEVANT) [dermatomes and myotomes, sensation, reflexes] L4 dermatome: Decreased sensation to light touch. L4 myotome: Weakness in ankle dorsiflexion. Patellar reflex: 2+ bilaterally. POWER TESTING [strength testing] Hip flexion: 4/5. Hip extension: 4/5. Knee flexion: 5/5. Knee extension: 5/5. Ankle dorsiflexion: 3/5. SPECIAL TESTS (transcribe all tests and the outcomes) Straight Leg Raise (SLR): Positive at 45 degrees on the left. PALPATION FINDINGS - SOFT TISSUE AND JOINT Tenderness to palpation over the lumbar paraspinal muscles and the left sacroiliac joint.