Reason for referral:
Referred by GP for assessment of persistent lower back pain impacting work performance.
Consent status:
Patient provided explicit verbal consent for assessment and treatment.
HPC:
Mr. John Smith, 45, presents with lower back pain radiating to his left buttock, ongoing for 3 months. Pain started insidiously with no clear mechanism of injury. It is worse with prolonged sitting and lifting, and slightly improves with walking. He describes it as a dull ache with intermittent sharp pains, particularly when bending. He has tried over-the-counter paracetamol with minimal relief. He has not sought any other professional medical advice for this condition prior to this referral.
Compensation/ claim:
No active compensation or insurance claims related to this condition.
Understand diagnosis:
Patient understands his diagnosis as 'general lower back pain' and is keen to understand the specific cause and how it affects his work.
How do you feel about Rx to date:
Patient feels current pain management (paracetamol) is ineffective and is frustrated by the lack of improvement.
Investigations:
No previous investigations (e.g., X-rays, MRI) have been performed for this complaint.
PC:
Lower back pain radiating to the left buttock.
NRS:
5/10 at rest, 7/10 with prolonged sitting/lifting.
Aggs:
Prolonged sitting, bending, lifting, static postures at work.
Eases:
Light walking, lying down.
24hr pattern:
Worse in the morning, eases slightly throughout the day with movement, but exacerbates in the evening after work.
Sleep affected?
Sleep is occasionally disturbed, patient reports difficulty finding a comfortable position, leading to broken sleep 2-3 nights a week.
P&N/numbness/altered sensation:
Reports occasional pins and needles in the left buttock, no numbness or altered sensation down the leg.
Swelling/Locking/Giving way
No joint swelling, locking, or giving way reported in the spine or lower limbs.
Driving
Driving for more than 30 minutes significantly aggravates symptoms, making his 45-minute commute challenging.
ADLs
Impacts ability to lift groceries, tie shoelaces, and engage in recreational gardening.
DH:
Paracetamol PRN (currently 1g QDS, ineffective).
PMH:
Asked: TB/Ca/DM/Epi/RA/CVS/Resp/Major Ops/#'s/Osetoporosis/Osteopenia /Hypertension/Circulatory Problems/Steroids/Anticoags
Pt Reports: History of childhood asthma, well-controlled. No other significant past medical history.
Smoker:
Non-smoker.
Alcohol intake:
Social drinker, 3-4 units per week.
General Health:
Generally good, apart from current back pain. Exercises regularly before this flare-up.
Mood stable:
Reports stable mood, but frustrated by pain and impact on work/hobbies.
Stress levels:
Moderate stress levels, primarily due to work demands and concern over back pain.
Home support:
Lives with wife, who is supportive.
What do you family think:
Family is concerned and encourages him to seek professional help.
Are they supportive:
Yes, very supportive.
Yellow flags present?:
Fear-avoidance behaviours (avoiding bending, lifting), low self-efficacy regarding recovery from pain, perception that pain means damage, and frustration with work impact.
Red flags:
Asked: Weight loss, fever, bladder/bowel changes, saddle anaesthesia, trauma, history of cancer.
Pt Reports: No red flag symptoms reported.
Spondyloarthritis:
No morning stiffness >30mins, no alternating buttock pain, no family history. Low likelihood.
Cervical Special Questions / VBI:
Asked: Dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, numbness (peri-oral).
Pt Reports: No VBI symptoms reported.
CES Screening
Asked: Bladder/bowel incontinence/retention, saddle anaesthesia, bilateral leg weakness, progressive neurological deficit.
Pt Reports: No CES symptoms reported.
SH:
Role: Office Administrator
Hrs: 37.5 hours/week, 9am-5pm
Main duties: Data entry, managing appointments, preparing reports, occasional lifting of archive boxes (up to 10kg).
In work / off sick (how long): Currently in work, but struggles significantly. Has taken 3 days off in the last month due to pain.
Length current fit note: N/A
Barriers for RTW: Pain with prolonged sitting, difficulty with lifting tasks, reduced concentration due to pain.
Enjoy job: Generally enjoys his job, finds it rewarding.
Symptom impact on job: Significant impact, reports reduced productivity and concentration, fears losing his job if pain continues.
What support would you expect from your colleagues?: Understanding and assistance with heavier lifting tasks.
WAS:
6/10 (Patient rates his current work ability as 6 out of 10 compared to his best).
Blue / Black flags present?:
Lack of employer understanding regarding pain, limited ergonomic support at work, concerns about job security.
Hobbies/ physical activity:
Used to enjoy gardening and cycling, both now limited by pain.
Meeting WHO guidelines:
Currently not meeting WHO guidelines due to pain limiting physical activity.
What are you hoping to get from today's consultation/ physiotherapy?
Patient hopes for an understanding of his condition, pain relief, and strategies to return to full work duties and hobbies without pain.
Patient perception of what they need:
Believes he needs exercises to strengthen his back and advice on how to sit without pain.
O.
Observation:
Standing: Appears comfortable, good posture, no obvious pelvic tilt or scoliosis. Walking: Normal gait pattern, no antalgic lean. Sitting: Slightly slumped posture, frequent shifting of weight.
Active ROM:
Lumbar Flexion: Limited to mid-range, pain at end range. Extension: Full range, pain at end range. Lateral Flexion: Full, pain to left. Rotation: Full, pain to left rotation.
Passive ROM:
Comparable to active ROM, no significant end-feel abnormalities.
Strength:
Bilateral hip flexion, extension, abduction, adduction, knee flexion, extension all 5/5. Ankle plantarflexion and dorsiflexion 5/5.
Neurological Assessment:
Lumbar:
Myotomes
Left / Right
L2 5/5 5/5
L3 5/5 5/5
L4 5/5 5/5
L5 5/5 5/5
S1 5/5 5/5
Dermatomes
Left / Right
L2 Normal Normal
L3 Normal Normal
L4 Normal Normal
L5 Normal Normal
S1 Normal Normal
Reflexes
Patella L3/4 2+ (Normal) 2+ (Normal)
Achilles L5/S1 2+ (Normal) 2+ (Normal)
SLR:
L 70 degrees (mild buttock pain)
R 90 degrees (no pain)
Slump test:
L Positive at 45 degrees (buttock pain)
R Negative
PKB:
L Negative
R Negative
Babinski: Negative
Clonus: Negative
Heel Shin co-ordination: Intact bilaterally
Palpation:
Tenderness noted over left paraspinal muscles at L4/L5 level. No significant palpable spasm or oedema.
Rx. Education of findings and working diagnosis
Explained findings suggest mechanical lower back pain with some neuropathic contribution to the left buttock. Emphasised that pain does not equate to damage and movement is safe. Discussed the role of prolonged static postures and lifting techniques in symptom exacerbation.
Explanation of rehabilitation importance and treatment options discussed:
Discussed the importance of a graded exercise program, ergonomic modifications at work, and pacing activities. Treatment options include manual therapy, specific exercises, and pain education. Emphasised active self-management approach.
Exercises:
Prescribed gentle lumbar mobility exercises (cat-camel, pelvic tilts), gluteal activation exercises (glute bridges), and core stability exercises (dead bugs). Advised patient to perform 3 sets of 10 repetitions, twice daily.
A .
Impression / working diagnosis:
Mechanical lower back pain with left gluteal pain, likely exacerbated by occupational postures and lifting. No red flags identified. Presence of yellow flags (fear-avoidance, job concerns) that need addressing.
Main subjective findings =
3-month history of lower back pain radiating to left buttock, NRS 5/10 at rest, 7/10 with activity. Aggravated by prolonged sitting/lifting, eased by walking. Impacting sleep, driving, ADLs, and work performance.
Main objective findings =
Tenderness over left L4/L5 paraspinal muscles. Limited and painful lumbar flexion, extension, and left lateral flexion ROM. Positive Left SLR and Slump test. Normal strength, sensation, and reflexes. No red flags or signs of neurological compromise.
Work status =
Currently in work but struggling; 3 days sick leave in the last month. Significant barriers to return to full, pain-free duties.
Main obstacles to work =
Prolonged sitting, heavy lifting tasks, fear of aggravating pain, and job security concerns.
P.
1. Commence prescribed home exercise program.
2. Provide ergonomic advice for workstation setup and lifting techniques.
3. Discuss pacing strategies for work tasks and daily activities.
4. Education on pain physiology and reducing fear-avoidance behaviours.
5. Schedule follow-up appointment in 1 week to review progress and progress exercises.
6. Consider discussing phased return to work with employer and potential workplace adjustments if no significant improvement.
Reason for referral:
[Reason patient was referred for assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Consent status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
HPC:
[History of presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Compensation/ claim:
[Details of any compensation or insurance claims] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Understand diagnosis:
[Patient's understanding of their diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
How do you feel about Rx to date:
[Patient's feelings about treatment received so far] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Investigations:
[Previous investigations and results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
PC:
[Presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
NRS:
[Numerical rating scale pain score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Aggs:
[Aggravating factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Eases:
[Easing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
24hr pattern:
[24-hour symptom pattern] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Sleep affected?
[Impact on sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
P&N/numbness/altered sensation:
[Pins and needles, numbness or altered sensation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Swelling/Locking/Giving way
[Joint swelling, locking or giving way symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Driving
[Impact on driving ability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
ADLs
[Activities of daily living impact] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
DH:
[Drug history and current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
PMH:
Asked: TB/Ca/DM/Epi/RA/CVS/Resp/Major Ops/#'s/Osetoporosis/Osteopenia /Hypertension/Circulatory Problems/Steroids/Anticoags
Pt Reports: [Patient reported past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Smoker:
[Smoking status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Alcohol intake:
[Alcohol consumption] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
General Health:
[General health status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Mood stable:
[Mood stability assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Stress levels:
[Current stress levels] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Home support:
[Available home support] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
What do you family think:
[Family's perspective on condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Are they supportive:
[Family support level] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Yellow flags present?:
[Psychosocial risk factors identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Red flags:
Asked: [Red flag symptoms screened for] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Pt Reports: [Patient reported red flag symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Spondyloarthritis:
[Spondyloarthritis screening questions and responses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Cervical Special Questions / VBI:
Asked: [Vertebrobasilar insufficiency symptoms screened for] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Pt Reports: [Patient reported VBI symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
CES Screening
Asked: [Cauda equina syndrome symptoms screened for] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Pt Reports: [Patient reported CES symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
SH:
Role: [Work role details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Hrs: [Working hours] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Main duties: [Primary work duties] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
In work / off sick (how long): [Current work status and duration] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Length current fit note: [Duration of current fitness note] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Barriers for RTW: [Barriers to return to work] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Enjoy job: [Job satisfaction] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Symptom impact on job: [How symptoms affect work performance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
What support would you expect from your colleagues?: [Expected colleague support] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
WAS:
[Work ability score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Blue / Black flags present?:
[Occupational and system factors identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Hobbies/ physical activity:
[Current hobbies and physical activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Meeting WHO guidelines:
[Whether meeting WHO physical activity guidelines] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
What are you hoping to get from today's consultation/ physiotherapy?
[Patient expectations from consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Patient perception of what they need:
[Patient's perception of their needs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
O. (Only include if any objective examination findings are mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Observation:
[Observation findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Active ROM:
[Active Range of Motion findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Passive ROM:
[Passive Range of Motion findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Strength:
[Strength assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological Assessment: (Only include if a neurological assessment is explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.)
Lumbar:
Myotomes (Only include if myotome assessment is mentioned in the transcript, contextual notes or clinical note; otherwise omit this subsection.)
Left / Right
L2 [Lumbar myotome assessment Left L2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar myotome assessment Right L2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L3 [Lumbar myotome assessment Left L3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar myotome assessment Right L3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L4 [Lumbar myotome assessment Left L4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar myotome assessment Right L4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L5 [Lumbar myotome assessment Left L5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar myotome assessment Right L5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
S1 [Lumbar myotome assessment Left S1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar myotome assessment Right S1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
Dermatomes
Left / Right
L2 [Lumbar dermatome assessment Left L2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar dermatome assessment Right L2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L3 [Lumbar dermatome assessment Left L3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar dermatome assessment Right L3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L4 [Lumbar dermatome assessment Left L4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar dermatome assessment Right L4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
L5 [Lumbar dermatome assessment Left L5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar dermatome assessment Right L5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
S1 [Lumbar dermatome assessment Left S1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Lumbar dermatome assessment Right S1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
Reflexes
Patella L3/4 [Lumbar reflex assessment L & R Patella] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Achilles L5/S1 [Lumbar reflex assessment L & R Achilles] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SLR:
L [Left Straight Leg Raise result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
R [Right Straight Leg Raise result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Slump test:
L [Left Slump test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
R [Right Slump test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PKB:
L [Left Prone Knee Bend result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
R [Right Prone Knee Bend result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Babinski: [Babinski test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Clonus: [Clonus test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Heel Shin co-ordination: [Heel-shin coordination test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cervical:
Myotomes (Only include if myotome assessment is mentioned in the transcript, contextual notes or clinical note; otherwise omit this subsection.)
Left / Right
C2 [Cervical myotome assessment Left C2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C3 [Cervical myotome assessment Left C3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C4 [Cervical myotome assessment Left C4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C5 [Cervical myotome assessment Left C5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C6 [Cervical myotome assessment Left C6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C7 [Cervical myotome assessment Left C7] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C7] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C8 [Cervical myotome assessment Left C8] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right C8] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
T1 [Cervical myotome assessment Left T1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical myotome assessment Right T1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
Dermatomes
Left / Right
C2 [Cervical dermatome assessment Left L2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C3 [Cervical dermatome assessment Left L3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C4 [Cervical dermatome assessment Left L4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C4] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C5 [Cervical dermatome assessment Left L5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C5] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C6 [Cervical dermatome assessment Left C6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C6] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
C7 [Cervical dermatome assessment Left C7] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right C7] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
T1 [Cervical dermatome assessment Left T1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit line.) [Cervical dermatome assessment Right T1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit.)
Reflexes
Biceps C5/6 [Cervical reflex assessment L & R Biceps] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Triceps C7 [Cervical reflex assessment L & R Triceps] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Brachioradialis reflex C6/C5 [Cervical reflex assessment L & R Brachioradialis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Finger jerk C8 [Cervical reflex assessment L & R finger jerk]
Hoffman's: [Hoffman's test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Finger to nose: [Finger-to-nose test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Clonus: [Clonus test result for cervical] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Rhomberg's: [Rhomberg's test result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ULTT1: [Upper Limb Tension Test 1 result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ULTT2a: [Upper Limb Tension Test 2a result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ULTT2b: [Upper Limb Tension Test 2b result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ULTT3: [Upper Limb Tension Test 3 result] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Palpation:
[Palpation findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Rx. Education of findings and working diagnosis
[Treatment provided and education given] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Explanation of rehabilitation importance and treatment options discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Exercises:
[Exercises prescribed or demonstrated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
A .
Impression / working diagnosis:
[Clinical impression and working diagnosis as stated by clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Do not invent or infer.)
Main subjective findings =
[Key subjective findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Main objective findings =
[Key objective findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Work status =
[Current work status assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Main obstacles to work =
[Primary barriers to work] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
P.
[Plan and next steps] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note.)
