Saturday, May 24, 2006
Routine Office Visit
Seen By: Dr. Clayton T. Hoyt
Chief Complaint - Lower Back Pain
SUBJECTIVE: On this visit, Miss Lincoln stated that she was experiencing
markedly decreased mid-line lower back pain. The symptoms were overall much better
with work and activities of daily living. The intensity of the symptoms is described
as being markedly decreased. She stated that today her symptoms were a 3 on a zero
to ten scale.
OBJECTIVE: On physical examination today, it was noted that the muscle spasm
has increased slightly, that the tenderness has increased and that the active range
of motion has more or less remained the same. Seated straight leg raise was positive
on the right at 90 degrees for the lower back pain and negative on the left at 90
degrees. The lower extremity dermatomes were found to be unremarkable. All of the
standard lower extremity muscle strengths were graded 5/5.
ASSESSMENT: The primary diagnosis is still lumbar disc herniation (722.10).
Maximum improvement is expected in 30 days. At present, I expect no residuals at
the end of treatment.
PLAN: Manipulation consisted of side-posture maneuvers to the right sacroiliac
joint and L5. Using needle acupuncture, the BL-64, BL-55 and BL-54 meridian points
were stimulated. Modalities performed to the area of chief complaint consisted of
60 lbs lumbar long axis traction for 10 minutes and continuous ultrasound at 1.0
w/cm2 for 20 minutes. Swiss ball exercises were performed in-office for 30 minutes.
They included the standard lumbar series (one set of 10 repetitions held for 10
seconds each). Today's treatment was tolerated well and afterward, she reported
feeling about the same. Her next visit is in 2 days. Outside the office, I have
instructed Miss Lincoln to begin to use moist heat for 10 minutes several times
per day and stretch the involved muscles regularly for 5 minutes several times per
day