SOLVED432

PHYSICAL THERAPY INITIAL EVALUATION AND BEHAVIOR/MAIN COMPLAINT: Patient has history of back pain off and on for five years. Recently, patient had severe back pain radiating down right lower extremity (RLE). Pain is worse when rising after lying; it is also severe upon sitting for more than a few minutes and when bending while sitting. Patient has no personal factors and/or comorbidities that impact the plan of care. Clinical presentation is stable. JOINT EVALUATION: Examination used standardized testing and measures to address range of motion limitation, right leg and hip. Pain upon straight leg raising right leg at 45 degrees. Pain is in right buttock and down posterior right thigh and leg. Pain also when flexing trunk on hips in same areas. MUSCLE/MOTOR EVALUATION: Not evaluated for muscle power. Patient has muscle spasms of moderate degree in the right lower quadrant (RLQ) of the back. FUNCTIONAL EVALUATION: Moves about easily in no apparent discomfort. When ambulating, no limp; but patient states pain is immediate upon coming to sitting or standing position. Twenty minutes was spent evaluating this patient using the standardized patient assessment instrument. PLAN: Modalities to be used; whirlpool and hot packs for six weeks, twice per week for
SCIENCE
HEALTH SCIENCE
NURSING

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