Subjective:
- Patient presents today with complaints of lower back pain and stiffness.
- The pain is described as a dull ache, located in the lumbar region, and has been present for the past 2 weeks. The pain is worse in the morning and after prolonged sitting.
- The patient reports that rest and over-the-counter pain relievers provide some relief.
- The symptoms have gradually worsened over the past two weeks.
- No previous episodes of similar pain.
- The pain is affecting the patient's ability to sit for long periods at work.
- No other associated symptoms.
Past Medical History:
- No significant past medical or surgical history.
- The patient works as a desk clerk and spends most of the day sitting.
- No family history of back pain.
- No known exposures.
- Up-to-date on all immunizations.
- No other relevant subjective information.
Objective:
- Vitals signs: BP 120/80, HR 72, RR 16.
- Physical examination reveals limited lumbar flexion and extension, positive slump test, and tenderness to palpation in the lumbar paraspinal muscles.
- No investigations with results.
Assessment:
- Likely diagnosis: Lumbar strain.
- Differential diagnosis: Disc herniation, facet joint dysfunction.
Treatment:
- Pain science education provided regarding the nature of the injury and the importance of movement.
- Mobilisation: Gr II PA R) L4/5 2x30secs, Unilateral soft tissue massage upper L) calf, etc
- 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc
- Home exercise program [HEP] provided: Core stabilisation exercises, 3 sets of 10 repetitions, twice daily. (Include reps, sets and frequency)
Plan:
- No investigations planned.
- Continue with physiotherapy treatment, including manual therapy and exercise.
- Advised to return to clinic in one week for follow-up.
Goals - changes to be achieved:
- Patient will demonstrate improved lumbar range of motion and reduced pain within two weeks.
- SMART Goal 2
Subjective:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Past Medical History:
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Assessment:
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Treatment:
-[List all educational treatment that was provided throughout session, e.g. pain science education] (Only include if explicitly mentioned)
-[List all hands on treatment provided throughout session, for example, Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc] (Only include if explicitly mentioned)
-[List all active therapy treatment provided throughout the session, for example, 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc] (Only include if explicitly mentioned)
-[List home exercise program [HEP] provided] (Include reps, sets and frequency) (Only include if explicitly mentioned)
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Goals - changes to be achieved:
- [Briefly state or list the goal(s) or changes to be achieved by the patient for SMART goal 1]
-SMART Goal 2 (only include SMART Goal 2, 3, 4 etc if the relevant SMART goals have been stated in the consult note or transcript; use the same template above for each SMART Goal listed)
(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 include in your note.)
