Monday, May 26, 2006
Routine Office Visit
Seen By: Dr. Clayton T. Hoyt
Chief Complaint - Lower Back Pain
SUBJECTIVE: Miss Lincoln reports that there has been marked improvement in
the lower back pain since her last treatment. She stated that today her symptoms
were a 1 on a zero to ten scale.
OBJECTIVE: The initial objective findings are decreasing. On evaluation today,
it was noted that the muscle spasm has nearly completely subsided, that the tenderness
has decreased by approximately 75% and that the active range of motion has returned
to normal. No fixations were found at L5 or the right sacroiliac joint.
ASSESSMENT: She appears to be more or less 90% improved. I expect maximum
improvement in the next 1-2 weeks.
PLAN: The treatment schedule will be three times per week until objective
findings are normal. Long term maintenance care is not expected to be required.
No manipulation was applied to the lumbar spine or the pelvis. No physical therapy
was performed today. Active rehabilitative exercises were performed for 30 minutes.
They included lumbar extension, flexion and rotation using progressive resistance
(two sets of 10 repetitions each @ 100 lbs. each). She tolerated today's treatment
well and afterward she stated that she was feeling better. Her next visit is in
2 days. She is to continue with the same home care plan. She can return to work
without restrictions.