John Doe : 10/05/09
Indications: Routine. Comparison 06/04/04.
SUBJECTIVE: The patient returns for followup of acute low back pain which initially began on 10/01/2009. He reports that he is doing a little better. He is a little nervous about going back to full duty. He thinks he can go, but at the same time, he is very nervous as there is a lot of work and a lot of box lifting and stuff. He also notes that he cannot take ibuprofen. He did not tell us previously that he has had multiple ulcers and that the NSAIDs are not good for him. He puts his pain level at about a 4.
OBJECTIVE: Examination today shows vital signs with a pulse of 68 and blood pressure 140/70. He has positive heel walk. He has positive toe walk. His range of motion: Right and left lateral flexion and lumbar flexion are completely normal. Extension is 20 degrees. On palpation, he has tenderness in the iliolumbar ligaments on the left hand side and over the facets on the left hand side at L4-5. DTRs are 0 to 1+ and symmetric.
ASSESSMENT: Acute low back pain.
REATMENT PLAN: I think that the biggest issue we have to face right now is his nervousness about returning to full duty. I think that he is going to do very well. I am going to clear him for full duty. I am going to use some Tylenol Extra Strength two of those up to three times a day on a prophylactic basis for the next couple of days. I still want the ice three times a day including before work, mid shift, and after work. He has already done it this afternoon before work now. We are going to see him back on Thursday. I think that he is going to do very well. We will show how good shape he already is in.