Osteopath Initial Consult

Initial Consultation Practitioner: Thomas Kelly Created: 1 November 2024, 10:00 AM Last updated: 1 November 2024, 10:30 AM Presenting Complaint: S: Localised pain in the lower back, right side Q: Dull and throbbing I: 7/10 at worst, currently 5/10 R: Pain radiates to the right hip T: Intermittent, worse in the morning AGG: Sitting for long periods, bending forward REL: Lying flat, applying heat Complaint History: ONSET: 2 months ago MOI: Lifting a heavy box CHRONO: Worsened over the past month PREV TTT: Physiotherapy sessions, chiropractic adjustments PREV INVEST/IMAGING: MRI scan showing mild disc bulge Past Medical History: PREV EPS: Similar episode 1 year ago ACC/INJ: None ILLNESSES: Hypertension MEDN: Lisinopril 10mg daily OPERATIONS: Appendectomy 5 years ago LEISURE: Regular swimming GOALS: SHORT: Reduce pain to 3/10 within 2 weeks INTERMED: Improve mobility and reduce stiffness LONG: Full recovery and return to normal activities Assessment: EXAMINATION: Tenderness in the lumbar region, reduced flexion RESTRICTED: Forward bending HT: Positive straight leg raise test PALP: Muscle tightness in the lumbar paraspinals SPECIAL TESTS: Negative for neurological deficits DIAGNOSIS: DX: Lumbar strain with mild disc bulge WORKING DX: N/A DDX: Sciatica, lumbar spondylosis INVEST: None required at this time Treatment: ST: Soft tissue massage to lumbar region ARTIC: Mobilisation of lumbar spine MET: Applied to lumbar paraspinals HVLA: None DN: None Treatment Plan: TTT FREQ & DUR: Twice weekly for 4 weeks, review after ADVICE: Avoid heavy lifting, maintain good posture REHAB: Core strengthening exercises Further Information: Patient advised to monitor symptoms and report any changes.