Wednesday, May 21, 2006
Routine Office Visit
Seen By: Dr. Clayton T. Hoyt
Chief Complaint - Lower Back Pain
SUBJECTIVE: She states that she is feeling somewhat better since her last
visit. Her score on the zero to ten scale today was a 7. The symptoms were overall slightly better with getting up from a
seated position.
OBJECTIVE: The objective findings are improving. On physical examination
today, it was noted that the muscle spasm in the lower back has decreased somewhat
and that the tenderness has decreased slightly. There was a decrease in the anterior antalgia.
ASSESSMENT: She has responded adequately to recent treatment. She appears
to be more or less 10% improved.
PLAN: I will maintain the
current treatment regimen so long as progress remains
constant. If her progress slows or stalls, I will reevaluate to determine further
options. Manipulation consisted of diversified maneuvers to T6, L5 and the right
sacroiliac joint. Lower extremity manipulation consisted of a lateral to medial
thrust to the right knee. Using needle acupuncture, the area of chief complaint
was treated using surround the dragon technique. 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 20 minutes. Passive rehabilitative exercises were performed for 30 minutes. They included lumbar flexion, extension and
rotation stretches (three sets of 10 repetitions each). Today's treatment was tolerated
well and afterward, she reported feeling better. She is to return in 1
day. She is to
continue with the same home care plan.