Physical Therapy Team Based Care Note 9/2/24 (Setting 1)​

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Subjective:

Patient is a 48-year-old male being seen for complaints of acute right buttock pain with diffuse radiation into posterior lower extremity and calf. He also reports a cramping/tightness sensation in his right calf. The pain began without mechanism approximately 2 weeks ago. Patient reports that the pain is getting worse, especially in his calf. Patient also reporting a history of chronic bilateral low back pain. He currently feels some low back pain but reports it is not that bad. Denies any previous history of right buttock or lower extremity symptoms associated with his low back pain. Notes that his buttock pain and lower extremity pain is made worse when he walks. He will start to feel the pain come on after approximately 5 minutes of walking. The pain will start in his calf and radiate proximally into his buttock. Reports that he needs to stop walking after approximately 10 minutes due to 7/10 pain level. Both buttock and lower extremity symptoms completely abate (0/10 pain level) within 2 minutes of sitting or lying down.

Patient notes that his low back pain worsens with excessive forward bending, lifting, and twisting movements, particularly during activities like yardwork or gardening. He will also feel his low back pain worsen with prolonged walking after about 1 mile. He notes that his low back pain is alleviated when he sits or lies down and takes only a few minutes to completely subside (0/10 pain). Patient denies any bilateral lower/upper extremity paresthesia, weakness, saddle paresthesia, recent infection, constitutional signs or symptoms, chest pain, difficulty breathing, changes in bowel and bladder function, night pain, or recent unexplained weight changes.

Past medical history is significant for active cancer (CML)- patient follows with oncology. Is currently on maintenance oral chemotherapy. Last appointment with oncologist was 06/29/24; type II diabetes- reports that his diabetes is “somewhat under control.” Is currently seeing a diabetic educator. Thinks his HbA1c is around 7%; hypercholesterolemia- takes a statin and reports it is controlled; hypertension- takes an ACE inhibitor and reports it is controlled; obesity- BMI: 42; anxiety- was previously undergoing behavioral therapy to address anxiety and depressed mood. Patient expressed being worried about his cancer diagnosis. Patient also reports a previous history of DVT in his left calf after his left total hip arthroplasty 2 years ago. Per patient, current symptoms do not feel like his previous DVT symptoms.

Current medication list includes: Atorvastatin, and aspirin for DVT prophylaxis, ponatinib for maintenance oral chemotherapy, metformin, and glipizide for diabetes management and lisinopril for hypertension management.

Patient works a desk job at Schneider National. He works from home most days per week and sits at his desk for most of his workday. Patient is recently divorced and lives alone in a ranch style home with 2 steps to enter. He receives social support from his adult son, mother, and other family members who live nearby. He enjoys gardening and genealogy.

He denies use of tobacco or illicit drugs but occasionally consumes alcohol socially. He stopped exercising due to worsening symptoms but had recently been using a stationary bike multiple times per week at the recommendation of his diabetic educator.
Current daily activities and ambulation are challenging due to the pain. His goals for PT are to improve pain with walking and be able to resume exercising to help lose weight and control his diabetes.
 

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Objective:

​Brief objective examination performed:

• Lower quarter neuro screen: Normal

• Posture/observation: Obese individual, excessive lumbar lordosis in static standing. No observable lateral shift

• Pain level: 0/10 pain at rest, standing

• Gait: Slight forward lean, wide base of support when ambulating in clinic (0/10 pain)

• Lumbar spine AROM: (0/10 pain at rest, standing)

  • ​Flexion: 0-40 (5/10 bilateral low back pain)

  • Extension: 0-15 (0/10 pain)

  • Right side bend: 0-25 (2/10 bilateral low back pain)

  • Left side bend: 0-25 (2/10 bilateral low back pain)

  • Right rotation: 80% (5/10 bilateral low back pain)

  • Left rotation: 80% (4/10 bilateral low back pain)

• Hip ROM: Grossly within functional limits (0/10 pain)

• Straight leg raise: Negative

• Slump test: Negative

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