Physiotherapist's initial note

Patient Information: - Name: John Smith, Date of Birth: 12/05/1978, Address: 123 High Street, Anytown, AB1 2CD, Contact Information: 01234 567890 - Employment status: Works as a builder, Physical demands of job: Heavy lifting and repetitive movements, Work-related activities: Lifting, carrying, and bending. - General exercise and activity levels: Walks the dog daily, enjoys gardening. Medical History: - Existing and past medical conditions: Lower back pain for 2 years, treated with physiotherapy previously. - Details of previous surgeries/treatments: None. - Allergies: None known. - Current medications: Ibuprofen as needed for pain. - Family medical history: Father with a history of osteoarthritis. Social History: - Smokes 10 cigarettes per day, drinks alcohol socially. Current Condition/Complaint: - Detailed description of primary injury, problem, complaint, or symptom: Acute lower back pain following lifting a heavy object at work. Pain is described as a sharp, stabbing pain in the lower back, radiating to the left buttock. Pain is worse with movement and prolonged sitting. - Date of onset and/or date of surgery: Onset 28 October 2024. - Description of how the injury occurred or complaint began: Lifted a heavy box at work. - Details of any prior therapy, interventions, and/or surgery: Previous physiotherapy for lower back pain two years ago. - Describe progression of complaint and nature of symptoms: Pain has worsened over the past few days. Pain is aggravated by bending, lifting, and twisting. Pain is relieved by rest. Patient Goals: - Short-term physiotherapy goals and time frame for achieving these goals: Reduce pain and improve mobility within 2 weeks. - Long-term physiotherapy goals and time frame for achieving these goals: Return to full work duties and prevent recurrence within 3 months. Objective: - Physical examination details: Lumbar spine range of motion limited in flexion, extension, and lateral flexion. Palpation reveals tenderness over the lumbar paraspinal muscles. Positive slump test. - Observations, tests, and measurements by the therapist: Visual gait analysis showed an antalgic gait. Numeric Pain Rating Scale (NPRS) score of 7/10 at rest. - Specific measurements and assessment findings: Lumbar flexion: 30 degrees (normal 60 degrees), Lumbar extension: 10 degrees (normal 20 degrees). Treatment: - Educational treatment: Provided education on pain management, posture, and body mechanics. - Hands-on treatment: Soft tissue massage to lumbar paraspinal muscles, Grade II PA mobilisation at L4/5. - Active therapy treatment: Core stability exercises, pelvic tilts, and gentle lumbar range of motion exercises. Assessment: - Therapist's professional opinion based on subjective and objective findings: Acute lumbar strain with associated muscle spasm. - Prioritized problems list: Pain, limited range of motion, muscle spasm. - Progress towards stated goals: Patient reported a slight reduction in pain after treatment. - Factors affecting progress and any need for modification in the plan: Smoking and heavy physical demands at work may be hindering progress. Plan will be modified to include advice on smoking cessation and work modifications. Plan: - Detailed treatment plan including interventions, frequency, and duration: Continue with soft tissue massage, mobilisation, and active exercises. Advised to attend physiotherapy twice a week for the next 4 weeks. - Anticipated goals and expected outcomes: Reduction in pain, improved range of motion, and return to work. - Equipment required and its usage: None. - Education strategies for the patient: Education on posture, body mechanics, and pain management strategies. - List home exercise program (HEP) provided, including details like reps, sets, and frequency: Core stability exercises: 3 sets of 10 repetitions, Pelvic tilts: 3 sets of 10 repetitions, Gentle lumbar range of motion exercises: 5 repetitions in each direction, performed 3 times a day. - Referrals to other professionals: Advised to consult with occupational health for work modifications.