Physiotherapist
ID checked & Verbal consent gained
Subjective:
History Of Presenting Complaint:
The patient, a 45-year-old male, presents with a 3-month history of lower back pain. The pain started insidiously after a day of gardening and has gradually worsened. He reports intermittent sharp pain radiating down his left leg to the knee, primarily with prolonged standing or walking.
A&E/GP:
Patient visited his GP two months ago regarding the back pain and was prescribed ibuprofen and advised rest. No A&E visits were reported for this complaint.
Presenting Complaint:
The primary complaint is chronic lower back pain with intermittent left leg radiculopathy.
P1) 7/10
Left-sided lower back pain, described as a dull ache with intermittent sharp, shooting pain radiating down the posterior aspect of the left thigh to the knee.
Aggs – Prolonged standing, walking more than 15 minutes, bending forward, lifting.
Eases – Lying down, applying heat pack, gentle stretching.
P2) 3/10
General stiffness in the lumbar spine, particularly in the mornings.
Aggs – Morning stiffness, sedentary posture.
Eases – Movement, light activity.
Headaches – Denies headaches.
Sleep – Reports disturbed sleep due to pain, often waking up 2-3 times per night and finding it difficult to get comfortable.
Red Flags – Denies any red flag symptoms such as bowel or bladder changes, saddle anaesthesia, unexplained weight loss, or fever.
Past Medical History – History of mild hypertension, managed with medication. No previous significant musculoskeletal issues.
Medication For Presenting Complaint:
Ibuprofen 400mg three times daily, taken as needed for pain relief.
Pre-Existing:
Amlodipine 5mg once daily for hypertension.
Social History:
The patient is a software engineer, working from home, primarily sedentary. He is married with two children. Non-smoker. Consumes alcohol socially (1-2 units per week). Engages in light walking 2-3 times per week, but this has reduced recently due to pain.
Activities Of Daily Living:
Difficulty with prolonged standing while cooking, struggle to walk his dog for desired distances, and experiences pain when lifting groceries or playing with his children. Finds it challenging to sit comfortably at his desk for extended periods.
Objective:
Lumbar spine observation reveals a mild loss of lumbar lordosis. Palpation noted tenderness over the L4-L5 and L5-S1 paraspinal muscles. Active range of motion for lumbar flexion was limited to 40 degrees with pain, extension to 10 degrees, and side bending was mildly restricted bilaterally. Straight leg raise test was positive on the left at 50 degrees with reproducible leg pain. Neurological examination showed intact sensation and motor strength in both lower extremities, with normal reflexes.
Impressions/Working Diagnosis:
Mechanical lower back pain with suspected left L5 radiculopathy.
Supporting Evidence:
The patient's reported history of insidious onset of pain exacerbated by mechanical movements, radiating pain in a dermatomal pattern, and positive straight leg raise test are consistent with the working diagnosis. Tenderness on palpation and reduced range of motion further support the mechanical component.
Treatment:
Manual therapy included soft tissue release to the lumbar paraspinal muscles and gluteal musculature. Lumbar mobilisation techniques, specifically posterior-anterior glides at L4-L5 and L5-S1, were performed.
Advice Given In Session:
Advised on appropriate posture during sitting and standing, ergonomic assessment of his home office setup, and pain management strategies including pacing activities. Educated on the importance of maintaining movement and avoiding prolonged static positions.
Plan:
Patient to continue with prescribed home exercise programme focusing on core stability and gentle lumbar mobility. Schedule follow-up appointment in one week to review progress and progress exercises. Refer to GP if no improvement or worsening of radicular symptoms for further investigation.
"ID checked & Verbal consent gained"
Subjective:
History Of Presenting Complaint:
[Detailed history of the current complaint including onset, duration, progression, and relevant background information] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
A&E/GP:
[Information about any previous visits to accident and emergency or a general practitioner related to the current complaint] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
Presenting Complaint:
[The primary complaint or reason for the current visit] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence, as its own paragraph.)
P1) [Pain score out of 10 for the first pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
[Description of the first pain or problem area including location, nature, and severity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence.)
Aggs – [Aggravating factors for the first pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Eases – [Easing factors for the first pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
P2) [Pain score out of 10 for the second pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
[Description of the second pain or problem area including location, nature, and severity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence.)
Aggs – [Aggravating factors for the second pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Eases – [Easing factors for the second pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
P3) [Pain score out of 10 for the third pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
[Description of the third pain or problem area including location, nature, and severity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a full sentence.)
Aggs – [Aggravating factors for the third pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Eases – [Easing factors for the third pain or problem area] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Headaches – [Presence, absence, or characteristics of headaches including frequency, location, and associated features] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Sleep – [Sleep quality, patterns, disturbances, or any sleep-related issues reported by the patient] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Red Flags – [Presence or absence of any serious clinical warning signs or symptoms requiring urgent attention] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on the same line.)
Past Medical History – [Relevant previous medical conditions, surgeries, or significant health events] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write in full sentences, with each item as a separate paragraph.)
Medication For Presenting Complaint:
[Medications currently being taken specifically for the presenting complaint, including name, dose, and frequency where stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each medication as a separate paragraph.)
Pre-Existing:
[Pre-existing medications or ongoing treatments not related to the presenting complaint, including name, dose, and frequency where stated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each medication as a separate paragraph.)
Social History:
[Relevant social factors including occupation, lifestyle, smoking status, alcohol use, and exercise habits] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
Activities Of Daily Living:
[The impact of the presenting complaint on the patient's daily activities, functional limitations, or abilities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each sentence as a separate paragraph.)
Objective:
[Physical examination findings, observations, measurements, and objective clinical data gathered during the assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each finding or logical group as a separate paragraph.)
Impressions/Working Diagnosis:
[The clinician's explicitly stated clinical impressions or working diagnosis based on the subjective and objective assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in full sentences, with each impression as a separate paragraph.)
Supporting Evidence:
[Evidence from the subjective and objective assessment that supports the clinical impression or working diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each piece of supporting evidence as a separate paragraph.)
Treatment:
[Treatments provided or administered during the session, including techniques, modalities, and areas treated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each treatment as a separate paragraph.)
Advice Given In Session:
[Summary of advice, education, and explanations provided to the patient during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each piece of advice as a separate paragraph.)
Plan:
[Treatment plan, follow-up instructions, referrals, or next steps discussed with the patient] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences, with each plan item as a separate paragraph.)
