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• X-Ray Report
• Narrative

SUBJECTIVE: Miss Lincoln is a 36 year old lady of Caucasian descent who appeared to be very uncomfortable. She stated that she does not exercise. She drinks alcohol socially and also smokes tobacco (1 pack per day). She is currently employed as a machine operator. She is 5 foot 4 inches tall and weighs 125 lb. On this visit, Miss Lincoln stated that she was experiencing constant moderate to severe mid-line lower back symptoms of a generally achy but occasionally sharp nature. These symptoms did not radiate. This problem was first noticed yesterday after she was mopping the floor. The symptoms were generally worse with walking and getting up from a seated position. Previous diagnostic tests which have been performed for this condition have included plain lumbar x-rays and a CAT scan of the lumbar spine. She has been seen by a neurosurgeon and her family physician. Past treatment has included non-steroidal anti-inflammatory medications and muscle relaxants. Her past medical history is significant for a partial hysterectomy. The remainder of the review of systems was unremarkable. The family history was unremarkable. The Oswestry Questionnaire administered today was graded at 35% which is considered by the questionnaire to be a moderate disability. She stated that today her lower back pain was a 9 on a 0 to 10 pain scale. She stated that today her symptoms were a 10 on a zero to ten scale

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OBJECTIVE: Kemp's test was found to be positive bilaterally for the lower back pain. Valsalva was positive. Supine straight leg raise was positive on the right at 30 degrees for the lower back pain and positive on the left at 90 degrees for the lower back pain. Braggard's sign was found to be positive bilaterally for the chief complaint. The left L4 dermatome was found to be hypoesthetic via pinprick. All of the other lower extremity dermatomes were unremarkable. Left foot eversion strength was noted to be grade 1. All of the lower extremity reflexes were normal. On palpation, moderate tenderness was evident in the erector spinae bilaterally and moderate to severe spasm was found in the thoraco-lumbar region bilaterally. On active testing in the lumbar region, lumbo-sacral flexion was measured at approximately 11% of normal due to pain and true flexion was measured at approximately 22% of normal. There was moderate anterior antalgia to the right. Her resting pulse was 75 BPM. The right brachial blood pressure was 120/80. See radiology report for the results of x-rays taken 5/19/97. On spinal evaluation, an extension and internal rotation fixation was noted at the right sacroiliac joint. Furthermore, fixations were noted from L2 through L5.

ASSESSMENT: The primary diagnosis is lumbar disc herniation (722.10) with associated myospasm (728.85). Maximum improvement is expected in 2-3 months. The current care is primarily corrective in nature but it is too early in care to determine the overall prognosis. No residuals are foreseen after the treatment of this condition is complete. The treatment may be prolonged due to her work activities, and the severity of the condition.

PLAN: The goals of care are to alleviate her symptoms, return all of the relevant objective findings to normal and clear all joint restrictions. The treatment schedule will be daily for 2 weeks, three times per week for 2 to 3 weeks and then twice per week for 2 to 3 weeks. If significant progress is not seen in 2 weeks, I am going to refer Miss Lincoln to Dr. Bill Jackson for a neurosurgical evaluation. I have recommended that prolonged sitting greater than 1/2 hour be avoided, lifting greater than 5 lb. for longer than 2 hours per day be avoided, and that a belt be used during lifting operations. Manipulation consisted of Cox flexion-distraction to the lumbar spine. Additional manipulation consisted of a drop table maneuver to the right sacroiliac joint. Today, using needle acupuncture, the BL-60, BL-55 and BL-54 meridian points were stimulated. Modalities used today on the lower back bilaterally consisted of full range interferential EMS set to patient tolerance for 20 minutes and myofacial release for 10 minutes. We discussed alternative treatments for her condition, the importance of her continuing care past symptomatic relief and the need for her to watch for any increase in weakness or numbness. We also discussed the need for her watch for changes in her bowel and bladder habits. Miss Lincoln indicated understanding of the items discussed. Today's treatment was tolerated well and afterward, she reported feeling slightly better. Her next visit is in 1 day. Outside the office, I have instructed Miss Lincoln to begin to ice the area for 30 minutes several times per day and do McKenzie exercises 10 reps several times per day. I have recommended that she take 2 tablets of Formula 303 - 3 times per day.