New Patient Consultation

Primary Complaint: Patient presents with lower back pain, described as a dull ache, radiating into the left buttock. The pain is exacerbated by prolonged sitting and bending. The patient reports the pain has been present for approximately four weeks. Secondary Complaint: Patient reports occasional headaches, primarily located in the occipital region, occurring approximately twice per week. These headaches are not associated with any specific activities. Date/ Mode of Onset: The lower back pain began approximately four weeks ago, following a weekend of heavy gardening. The patient recalls feeling a sudden strain while lifting a heavy bag of soil. Course: The lower back pain initially presented as a mild ache, gradually worsening over the first week. The pain has remained relatively consistent since then, with occasional flares after periods of increased activity. The headaches have been present for several months, with no significant change in frequency or intensity. Type of Pain / Severity: The lower back pain is described as a dull ache, rated as a 5/10 on the pain scale. The pain radiates into the left buttock. The headaches are described as a pressure-like sensation, rated as a 3/10 on the pain scale. Frequency / Duration: The lower back pain is present most of the day, with exacerbations during prolonged sitting or bending. The headaches occur approximately twice per week, lasting for several hours. Previous Episodes: The patient reports a similar episode of lower back pain approximately two years ago, which resolved with rest and over-the-counter pain medication. Aggravating Factors: Prolonged sitting, bending, and lifting heavy objects aggravate the lower back pain. The headaches are not associated with any specific triggers. Relieving Factors: Rest and over-the-counter pain medication provide some relief from the lower back pain. The patient has not identified any specific relieving factors for the headaches. Sleep / Night Sweats / Diet: The patient reports sleeping approximately 7-8 hours per night. No night sweats are reported. The patient's diet is generally healthy, with no significant changes related to the symptoms. Previous Treatment (X-rays, MRI, CAT scan, Urine, Bloods, Biopsy, GP DX, Specialist DX): The patient has not sought any previous medical treatment for the current episode of lower back pain. The patient reports seeing their GP for the headaches, who advised them to take over the counter pain relief. Associated Symptoms: No associated symptoms are reported. General Past History of Trauma either macrotrauma or repeated microtrauma; accidents, Fractures, Disease, surgeries, allergies, pregnancies, other medical history, Spinal History of strain: The patient reports no history of trauma, fractures, diseases, surgeries, allergies, or pregnancies. The patient works as a desk based office worker and sits for prolonged periods. (Health Aim/ goals) If we could change anything about your health that would have the biggest impact on your quality of life not just now but also in five years time - what would they be. What would be the 1, 2, 3 goals? The patient's primary goal is to eliminate their lower back pain and headaches. They also aim to improve their posture and overall spinal health to prevent future episodes. On a scale of 0-10 how motivated are you to truly fix this problem without drugs or surgery? Why isn't it lower? The patient rates their motivation level as an 8/10. They are motivated to seek chiropractic care to avoid relying on medication and to address the underlying cause of their pain. Do you have any obstacles that will prevent you from getting care in our centre such as time, transportation, travel a lot. The patient has no obstacles to receiving care at the centre.