Initial Detailed Consult

Presenting Complaint: Lower back pain - Patient reports experiencing lower back pain for the past two weeks, exacerbated by prolonged sitting and bending forward. Medical History: No significant medical history. Medications: Ibuprofen 400mg as needed for pain. Examination SFMA Cervical Flexion: FN Cervical Extension: FP - mild discomfort noted Cervical Rotation: FN Multisegmental Flexion: DN - limited range of motion Multisegmental Extension: FN Multisegmental Rotation: FN Upper Extremity #1: FN Upper Extremity #2: FN Single Leg Balance: FN - eyes open, 30 seconds Overhead Squat: FP - slight imbalance noted MUSCLE TESTING SERRATUS ANTERIOR: L 5/5, R 5/5 LATISSIMUS DORSI: L 5/5, R 5/5 UPPER TRAPEZIUS: L 5/5, R 5/5 MIDDLE TRAPEZIUS: L 5/5, R 5/5 LOWER TRAPEZIUS: L 5/5, R 5/5 PECTORALIS MAJOR - TRANSVERSE: L 5/5, R 5/5 PECTORALIS MAJOR - OBLIQUE: L 5/5, R 5/5 MID DELTOID: L 5/5, R 5/5 ANTERIOR DELTOID: L 5/5, R 5/5 POSTERIOR DELTOID: L 5/5, R 5/5 BICEPS: L 5/5, R 5/5 BRACHIALIS: L 5/5, R 5/5 BRACHIORADIALIS: L 5/5, R 5/5 TRICEPS: L 5/5, R 5/5 WRIST FLEXORS: L 5/5, R 5/5 FLEXOR CARPI ULNARIS: L 5/5, R 5/5 FLEXOR CARPI RADIALIS: L 5/5, R 5/5 WRIST EXTENSORS: L 5/5, R 5/5 EXTENSOR CARPI ULNARIS: L 5/5, R 5/5 EXTENSOR CARPI RADIALIS: L 5/5, R 5/5 FINGER FLEXORS: L 5/5, R 5/5 FINGER EXTENSORS: L 5/5, R 5/5 FINGER ABDUCTORS: L 5/5, R 5/5 LUMBRICALS: L 5/5, R 5/5 THUMB EXTENSION: L 5/5, R 5/5 THUMB FLEXION: L 5/5, R 5/5 THUMB ABDUCTION: L 5/5, R 5/5 THUMB ADDUCTION: L 5/5, R 5/5 THUMB LITTLE FINGER OPPOSITION: L 5/5, R 5/5 HAMSTRINGS: L 5/5, R 5/5 GLUTEUS MAXIMUS: L 5/5, R 5/5 RSLR: L 5/5, R 5/5 PSOAS: L 5/5, R 5/5 HIP ABDUCTORS: L 5/5, R 5/5 GLUTEUS MEDIUS: L 5/5, R 5/5 GUTEUS MINIMUS: L 5/5, R 5/5 TENSOR FASCIA LATAE: L 5/5, R 5/5 HIP ADDUCTORS: L 5/5, R 5/5 RECTUS FEMORIS: L 5/5, R 5/5 QUADRICEPS: L 5/5, R 5/5 POPLITEUS: L 5/5, R 5/5 GASTROCNEMIUS: L 5/5, R 5/5 SOLEUS: L 5/5, R 5/5 TIBIALIS ANTERIOR: L 5/5, R 5/5 PERONEAL GROUP: L 5/5, R 5/5 TOE FLEXORS: L 5/5, R 5/5 TOE EXTENSORS: L 5/5, R 5/5 EXTENSOR HALLUCIS LONGUS: L 5/5, R 5/5 FLEXOR HALLUCIS LONGUS: L 5/5, R 5/5 TOE ABDUCTORS: L 5/5, R 5/5 Cervical Testing C COMPRESSION: - C DISTRACTION: - C KEMPS: - FORAMINAL COMPRESSION - LAT FLEXION: - FORAMINAL COMPRESSION - ROTATION: - FORAMINAL COMPRESSION - KEMPS OVERPRESSURE: L -, R - UPPER LIMB TENSION TESTS RADIAL NERVE: - MEDIAN NERVE 1: - MEDIAN NERVE 2: - ULNAR NERVE: - Thoracic Testing 1st RIB RESTRICTION: L -, R - ADAM'S FORWARD BEND: - ADSON'S TEST: L -, R - RESPIRATION: Normal diaphragmatic breathing THORACIC ROTATION/EXTENSION, HAND ON OPPOSITE SHOULDER: L FN, R FN THORACIC ROTATION/EXTENSION, HAND BEHIND LOWER BACK: L FN, R FN THORACIC ROTATION/EXTENSION, HAND BY EAR, ELBOW OUT: L FN, R FN Shoulder Testing EMPTY CAN: L -, R - BEAR HUG: L -, R - HORNBLOWERS/INFRASPINATUS: L -, R - SPEEDS: L -, R - O'BRIENS: L -, R - YERGASONS: L -, R - BICEPS LOAD TEST: L -, R - NEERS: L -, R - ACROMIOCLAVICULAR JOINT: L -, R - STERNOCLAVICULAR JOINT: L -, R - SULCUS SIGN: L -, R - GLENOHUMERAL AP GLIDE: L -, R - PAINFUL ARC: L -, R - ARM DROP TEST: L -, R - Elbow, Wrist and Hand Testing CARPAL COMPRESSION: - SCAPHOID COMPRESSION: - TFCC COMPRESSION: - MEDIAL ELBOW PALPATION: - LATERAL ELBOW PALPATION: - PHALENS TEST: - REVERSE PHALENS TEST: - GRIP: Normal Functional and Structural HANDEDNESS: Right-handed GAIT - WALKING: Normal GAIT - RUNNING: Normal FOOTWEAR: Appropriate SQUAT - BODYWEIGHT: Normal SQUAT - OVERHEAD: Slight imbalance SQUAT - BARBELL: Not tested SQUAT - SANDBAG: Not tested NECK FLEXION MOVEMENT PATTERN: Normal DEEP NECK FLEXOR ENDURANCE: Normal TRUNK FLEXION MOVEMENT PATTERN: Normal SHOULDER ABDUCTION: Normal PUSH UP: Normal WEIGHTED SHOULDER FLEXION: Normal SEATED TOE TOUCH: Normal HIP EXTENSION MOVEMENT PATTERN: Normal HIP FLEXION MOVEMENT PATTERN: Normal HIP ABDUCTION MOVEMENT PATTERN: Normal LEG LENGTH DISCREPANCY: None Range of Motion Testing SEATED NECK RANGE OF MOTION: Normal SUPINE NECK RANGE OF MOTION: Normal SUPINE UPPER CERVICAL RANGE OF MOTION: Normal SEATED TRUNK ROTATION: Normal SHOULDER ABDUCTION: Normal SHOULDER FLEXION: Normal SHOULDER EXTENSION: Normal SHOULDER ROTATION SEATED: Normal SHOULDER ROTATION PRONE: Normal ELBOW FLEXION: Normal ELBOW EXTENSION: Normal ELBOW SUPINATION: Normal ELBOW PRONATION: Normal WRIST FLEXION: Normal WRIST EXTENSION: Normal WRIST ULNAR DEVIATION: Normal WRIST RADIAL DEVIATION: Normal FINGER FLEXION: Normal FINGER EXTENSION: Normal FINGER ABDUCTION: Normal THUMB ABDUCTION: Normal THUMB EXTENSION: Normal THUMB OPPOSITION: Normal HIP ROTATION SEATED: Normal HIP ROTATION PRONE: Normal HIP ROTATION SUPINE: Normal HIP FLEXION: Normal HIP EXTENSION: Normal HIP ABDUCTION: Normal HIP ADDUCTION: Normal KNEE FLEXION: Normal KNEE EXTENSION: Normal KNEE INTERNAL ROTATION: Normal KNEE EXTERNAL ROTATION: Normal ANKLE DORSIFLEXION: Normal KNEE TO WALL: Normal ANKLE PLANTARFLEXION: Normal ANKLE EVERSION: Normal ANKLE INVERSION: Normal Working Diagnosis: Mechanical lower back pain Treatment: Chiropractic adjustments focusing on lumbar spine, soft tissue therapy, and stretching exercises. Home Care: Patient advised to perform daily stretching exercises focusing on the lower back and hamstrings. Treatment Plan: Follow-up in one week to assess progress and adjust treatment as necessary.