Patient Evaluation Note Outline
Patient Name: Alanis Durgan
Date: October 8, 2089
DOB: January 1, 2050
MRN: 123456
Clinician: Dr. [Your Name], MD
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:
Medications:
Lisinopril 10 mg daily
Ibuprofen as needed
Social History:
Family History:
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:
Mechanical lower back pain is likely due to muscle strain or posture-related issues.
Hypertension is well-controlled.
Plan:
Educate the patient on proper ergonomics at the workplace.
Recommend physical therapy focused on strengthening and flexibility exercises.
Continue ibuprofen as needed for pain management; consider prescribing a muscle relaxant if symptoms persist.
Follow-up in 4 weeks or sooner if symptoms worsen.
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