🩺 Record Detail

Patient Info

Name: Mr. Smith
Age: 45 years
Date: 2025-05-30 13:16:29

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Clinical Notes

Subjective

  • Patient: Mr. Smith, 45 years old.

  • Primary Concern: Experiencing persistent lower back pain.

    • Reports pain started a month ago after lifting a heavy box at work.

    • Describes the pain as a dull ache that worsens with movement.

  • Pain Characteristics:

    • Rates the pain as 6 out of 10 on the pain scale.

    • States the pain does not radiate to the legs but feels like a constant discomfort in the lower back.

  • Impact on Daily Life:

    • Mentions difficulty in bending and lifting objects.

  • Medication Usage:

    • Takes over-the-counter pain relievers occasionally for the back pain.

Objective

  • Physical Examination:

    • Limited range of motion in the lumbar spine.

    • No visible signs of inflammation or deformity.

Assessment

  1. Mechanical Low Back Pain: Likely due to the heavy lifting incident at work.

Plan

  1. Pain Management:

    • Advise on proper lifting techniques to prevent exacerbation of pain.

    • Recommend physical therapy for strengthening and flexibility exercises.

    • Discuss the option of using heat or ice packs for pain relief.

  2. Follow-Up:

    • Schedule a follow-up appointment in two weeks to assess response to interventions and make any necessary adjustments.
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