Friday, May 23, 2006
Routine Office Visit
Seen By: Dr. Clayton T.
Hoyt
Chief Complaint - Lower Back Pain
SUBJECTIVE: Miss Lincoln reports that she is feeling much better since
her last visit. Her score on the zero to ten scale today was a 5. The symptoms
were overall much better with walking and getting up from a seated position. The
intensity of the symptoms is described as being markedly decreased.
OBJECTIVE: Her objective findings are improving. Since the last visit,
the muscle spasm in the thoraco-lumbar area has nearly completely subsided, the
tenderness has decreased considerably and the active range of motion has
increased by approximately 50%.
ASSESSMENT: She is progressing well at this point and the prognosis is
unchanged. In my opinion, she appears to be approximately 40% improved. The
primary diagnosis is still lumbar disc herniation (722.1).
PLAN: Manipulation consisted of Cox flexion-distraction to the lumbar
spine. Additional manipulation consisted of a side-posture maneuver to the right
sacroiliac joint. Today, using needle acupuncture, the BL-60, BL-55 and BL-54
meridian points were stimulated. Modalities performed to the thoraco-lumbar area
consisted of short wave diathermy for 10 minutes and intersegmental traction for
10 minutes. We discussed the importance of Miss Lincoln performing all
prescribed home care and the importance of keeping her regular scheduled
appointments. She tolerated today's treatment well and afterward she stated that
she was feeling better. Her next visit is in 1 day. She is to continue with the
same home care plan.