Patient Evaluation Note Outline

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Patient Name: Alanis Durgan
Date: October 8, 2089
DOB: January 1, 2050
MRN: 123456
Clinician: Dr. [Your Name], MD

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Chief Complaint:

The patient presents with complaints of persistent lower back pain for the past three weeks.

History of Present Illness:

Alanis Durgan is a 39-year-old male who reports experiencing lower back pain that started approximately three weeks ago. The pain is described as a dull ache, rated 6/10 in intensity, and worsens with prolonged sitting and bending. He denies any history of trauma. The patient has attempted over-the-counter analgesics (ibuprofen) with minimal relief. No associated symptoms such as leg weakness or bowel/bladder dysfunction.

Past Medical History:

• Hypertension is well-controlled with medication

• No previous surgeries

• No known drug allergies

Medications:

• Lisinopril 10 mg daily

• Ibuprofen as needed

Social History:

• Non-smoker

• Occasional alcohol use

• Works as a software engineer, a sedentary lifestyle

Family History:

• Father with a history of coronary artery disease

• Mother with hypertension

Review of Systems:

• Constitutional: No fever, weight loss

• Musculoskeletal: Reports lower back pain; no joint swelling or stiffness

• Neurological: No headaches, dizziness, or weakness

Physical Examination:

• Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 98.6°F

• General: Alert, in no acute distress

• Back: Tenderness noted in the lumbar region, no palpable muscle spasm

• Range of Motion: Limited flexion due to pain, extension and lateral bending within normal limits

• Neurological: Normal strength and sensation in lower extremities; reflexes intact

Assessment:

1. Mechanical lower back pain is likely due to muscle strain or posture-related issues.

2. Hypertension is well-controlled.

Plan:

1. Educate the patient on proper ergonomics at the workplace.

2. Recommend physical therapy focused on strengthening and flexibility exercises.

3. Continue ibuprofen as needed for pain management; consider prescribing a muscle relaxant if symptoms persist.

4. Follow-up in 4 weeks or sooner if symptoms worsen.

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