CC: Lower back pain radiating down left leg to knee
S: Daily Encounter: Low back pain following a work injuryDx: M54.50 - Low back pain, unspecified 3 days ago while unloading a truck and lifting a 50-pound box.
Pain Scale: 7/10
Patient reports: Pain radiates across lower back and down left leg to approximately the knee. Symptoms worsened the morning after the injury. Sitting and bending forward are worst; standing and walking feel better. Rolling over at night causes awakening due to pain. Patient has had similar issues two years ago that resolved with care.
Current Medications: Ibuprofen 800 mg twice daily, lisinopril 10 mg daily, multivitamin.
O: Daily Objective Findings:
- Postural Findings: Shifting weight away from the left side.
- Spinal Restriction(s)/Subluxation(s): bilateral L4, bilateral L5Dx: M99.03 - Segmental dysfunction, lumbar.
- Pain/Tenderness: Tenderness at L4 and L5 on both sides.
- Muscle Spasm(s)Dx: M62.830 - Muscle spasm of back: Surrounding muscles of L4 and L5 are tight and in spasm.
- ROM Concern(s): Lumbar range of motion is decreased; forward flexion is roughly half of normal. Extension limited to about 10 degrees. Left side bending reproduces leg pain.
- Neuro: Right straight leg raise is negative; left straight leg raise is positive starting at 45 degrees. Leg strength and reflexes are normal.
A: Daily Assessment: Acute lumbar strain with radiculopathyDx: M54.16 - Radiculopathy, lumbar region following a lifting injury. Radiating pain suggests nerve irritation without current loss of strength or reflex.
Determination of Care: Continued care is appropriate because joint restrictions, muscle spasms, and leg symptoms persist.
P: Today's Treatment:
- Chief Complaint: Lower back pain radiating down left leg to knee.
- Primary Treatment: Diversified technique to the bilateral L4, bilateral L5CPT: 98940 - CMT 1-2 regions spinal level(s).
- Adjunctive therapies: Soft tissue therapy for muscle spasmCPT: 97140 - Manual therapy; ice for 15 minutes three or four times a day with a towel between skin and ice.
Patient Education: Use pillow under knees when sleeping on back. Avoid heavy lifting for one week (limit weight to under 20 pounds). Stop and stretch while driving at least once per hour.
Follow-up: Recheck in one week.