Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Low back pain (LBP)
History of Present Illness:
Describe the onset, location, character, and duration of the low back pain.
Inquire about aggravating and alleviating factors (e.g., worse with sitting, better with walking).
Mention any radiation of pain (e.g., down the leg – sciatica).
Briefly describe any associated symptoms (e.g., numbness, tingling, weakness, difficulty walking).
Ask about prior episodes of low back pain and their course of resolution.
Past Medical History:
Include any relevant past medical history, such as:
Back injuries or surgeries
Underlying medical conditions (e.g., arthritis, osteoporosis)
Risk factors for LBP (e.g., obesity, smoking)
Medications:
List all current medications, including pain relievers used for LBP.
Social History:
Inquire about occupation and activities that may contribute to LBP (e.g., heavy lifting, prolonged sitting).
Family History:
Not typically relevant for LBP, but can be included if pertinent (e.g., family history of inflammatory conditions).
Physical Exam:
General observation: Assess posture, gait, and any signs of discomfort.
Spine exam: Look for tenderness, deformity, or range of motion limitations.
Neurological exam: Evaluate muscle strength, sensation, and reflexes in the lower extremities (to assess for nerve involvement).
Functional assessment: Observe the patient performing basic movements (e.g., squatting, standing on toes) to assess functional limitations.
Imaging Studies (if performed):
X-rays: May be used to rule out fractures or bony abnormalities.
MRI scan: More detailed imaging to assess for disc herniation, ligament sprains, or spinal stenosis (narrowing of the spinal canal).
Assessment:
Diagnosis: State “acute low back pain” or “chronic low back pain” based on duration (acute – less than 6 weeks, chronic – more than 12 weeks).
Severity: Briefly describe the perceived severity of pain and functional limitations.
Red flags: Mention if there are any “red flags” suggesting a more serious underlying condition, such as:
Fever
Urinary incontinence or difficulty controlling bowel movements
Saddle anesthesia (numbness in the inner thighs and genitals)
Progressive weakness or paralysis
History of cancer or trauma
Plan:
Treatment:
Outline the treatment plan based on the severity and individual needs. This may include:
Self-care: Rest, ice application, heat application (after initial inflammation subsides), activity modification, and ergonomic modifications.
Medications: Pain relievers (over-the-counter or prescription), muscle relaxants (short-term use).
Physical therapy: Exercises to improve core strength, flexibility, and posture.
Manual therapy: Techniques like massage or manipulation may be helpful for some patients.
Evaluation for interventional pain procedures or surgery: May be considered for chronic or severe LBP with nerve involvement or no response to conservative treatment.
Education: Educate the patient about LBP, proper lifting techniques, posture, and the importance of self-care strategies.
Follow-up:
Schedule a follow-up visit within 1-2 weeks to assess response to treatment and discuss prognosis for recovery.
Advise the patient to return sooner if symptoms worsen or red flags develop.