Tuesday, May 20, 2006
Routine Office Visit
Seen By: Dr. Clayton T. Hoyt
Chief Complaint - Lower Back Pain
SUBJECTIVE: Miss Lincoln describes that there is no significant change in
her lower back pain since the last treatment. Today, her zero to ten score was an
8.
OBJECTIVE: There is no change in objective findings since last visit. On
evaluation today, it was noted that the muscle spasm in the lower back has not changed
significantly, that the tenderness has remained more or less unchanged and that
the active range of motion has remained the same. On spinal evaluation, an extension and left
rotation fixation was noted at L5.
ASSESSMENT: She is making acceptable progress toward resolution of
the chief complaint. The primary diagnosis is still lumbar disc herniation (722.10).
PLAN: I will continue with the same treatment program so long as progress
is seen. Manipulation consisted of side-posture maneuvers to L5 and the right sacroiliac joint. Today, using electro-acupuncture, the BL-60, BL-5554 and ST-63 meridian points were stimulated. Modalities used today on the area of chief complaint consisted
of short wave diathermy for 10 minutes and 40 lbs. lumbar long axis traction for 10 minutes. Her next visit is in 1
day. While at home, I have instructed Miss Lincoln to continue to do McKenzie exercises 10 reps several times
per day.