History of Present Illness
John Doe, a 45-year-old male, presents to physical therapy with complaints of lower back pain that began insidiously three months ago. He reports no specific event that triggered the pain.
Signs and Symptoms
John describes his pain as a constant dull ache with occasional sharp twinges.
Pain at present
John rates his current pain as 6 out of 10.
Aggravating and easing factors
Aggs: Prolonged sitting, bending forward, and lifting heavy objects.
Ease: Resting in a reclined position and applying heat.
Activity Limitations
John is unable to perform his usual gardening activities and has difficulty sitting for extended periods at work.
Co-morbidities/Complexities
Hypertension
Prior treatments / surgeries
John has tried over-the-counter pain medications and chiropractic adjustments with minimal relief. He is not seeing any other providers for this issue.
Prior imaging /studies
An MRI showed mild disc degeneration at L4-L5.
Goals
John aims to return to his gardening activities and sit comfortably at work without pain.
OBJECTIVE
- Posture: Slight forward head posture
- Range of Motion: Limited lumbar flexion
- Strength: Weakness in core muscles
- Palpation: Tenderness over the lumbar paraspinals
Assessment:
John Doe presents with chronic lower back pain likely due to mild disc degeneration at L4-L5. His symptoms and functional limitations suggest he would benefit from skilled physical therapy to improve core strength and flexibility, which will help alleviate pain and restore function.
GOALS
- Improve lumbar flexion range of motion by 20 degrees within 8 weeks.
- Increase core muscle strength to 4/5 on manual muscle testing within 10 weeks.
- Sit comfortably for 2 hours without pain within 6 weeks.
- Return to gardening activities for 30 minutes without pain within 12 weeks.
- Reduce pain level to 3/10 during daily activities within 8 weeks.
Plan:
- Initiate a core strengthening and flexibility program.
- Educate on proper body mechanics and posture.
- Plan for follow-up in 2 weeks to reassess progress.
History of Present Illness
[Report in chronological order describing the patient and why they are coming to physical therapy]
[Describe how the injury occurred. Report as βinsidious onsetβ if no specific event occurred]
Signs and Symptoms
[Report descriptor words the patient uses to describe their pain. If they arenβt able to describe their pain, report as βpainβ]
Pain at present
[Report patients pain at present rated from 0 to 10]
[If no pain number is given, report it as mild, moderate, or severe]
Aggravating and easing factors
Aggs: [Report all activities that aggravate patients reported pain][Report as none if nothing makes it worse]
Ease: [Report all activities that make the patients reported pain better][Report as none if nothing makes it better]
Activity Limitations
[List any activities the patient cannot perform due to their injury]
Co-morbidities/Complexities
[List any co-morbidities or other diseases the patient has here]
[Report βnoneβ if patient has no co-morbidities]
Prior treatments / surgeries
[List any treatments including injections, chiropractic, other PT, or surgeries for the issue they are coming to physical therapy for today]
[List all providers they are seeing for this issue]
[Report βNoneβ if they havenβt received any treatments, surgeries, and arenβt seeing any other providers]
Prior imaging /studies
[List findings of any imaging studies they have had including but not limited to x-ray, CT scan, MRI, fluoroscopy, etc]
[Report βnoneβ if they have not had any imaging]
Goals
[List the patients stated goals with physical therapy]
OBJECTIVE
[Report all objective findings] (List it in a logical order with headers when appropriate)
Assessment:
[Write an assessment as a paragraph summarizing the patients history and objective measures.]
[Include the likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [Include why the patient would benefit from skilled physical therapy]
GOALS
[Write 5 functional physical therapy goals that are Specific, Measurable, Achievable, Relevant, and Time-bound that are 6 weeks or longer. List them as bullets, not numbers.]
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counseling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
