Medical Specialty:

Sample Name: Low Back Pain from Exercise

Description: Patient having low back pain after doing exercise
(Medical Transcription Sample Report)

The patient presented with complaints of low back pain that developed after engaging in exercise activities. The pain was primarily localized to the lower back region and was described as a dull ache that worsened with movement. The patient reported that the pain started approximately three days ago after performing a series of weightlifting exercises at the gym. He mentioned that he had not experienced any prior episodes of significant low back pain.

Upon physical examination, the patient exhibited tenderness and mild muscle spasm in the lumbar region. No signs of inflammation or redness were observed. Range of motion testing revealed a decreased ability to flex the lumbar spine and perform forward bending without discomfort. The patient also reported pain upon palpation of the paraspinal muscles in the lower back.

Based on the subjective and objective findings, it is likely that the patient is experiencing acute low back pain, possibly due to overexertion during exercise. The pain is consistent with a muscular strain or sprain in the lumbar region. Further diagnostic tests, such as imaging studies, may be considered if symptoms persist or worsen.

1. Pain Management: The patient will be advised to utilize over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, to alleviate discomfort and reduce inflammation as needed. Acetaminophen may also be used for pain relief, following appropriate dosing instructions. Additionally, topical analgesics containing menthol or capsaicin may provide localized relief.

2. Rest and Activity Modification: The patient will be advised to temporarily avoid activities that exacerbate the pain, including the specific exercises that triggered the symptoms. Adequate rest and avoidance of strenuous activities will allow the injured tissues to heal. Low-impact exercises, such as swimming, cycling, or using an elliptical machine, can be recommended to maintain fitness without aggravating the low back pain.

3. Physical Therapy: Referral to a physical therapist will be made for further evaluation and development of a customized exercise program. The program will focus on strengthening the core and supporting muscles, improving flexibility, and promoting proper body mechanics to prevent future injuries. Core strengthening exercises such as planks, bridges, and abdominal crunches, as well as flexibility exercises targeting the hamstrings, hip flexors, and lower back muscles, will be incorporated into the treatment plan.

4. Education: The patient will be educated about the importance of maintaining good posture, using proper lifting techniques, and gradually increasing the intensity and duration of exercise to prevent recurrence of low back pain. They will also be advised to consult with a healthcare professional before resuming exercise activities. Proper lifting techniques, including bending at the knees, keeping the back straight, and lifting with the legs, will be emphasized to prevent further strain on the lower back.

5. Follow-up: A follow-up appointment will be scheduled in 3 weeks to assess the patient's progress, reassess symptoms, and modify the treatment plan if necessary.

Keywords: orthopedic, low back pain, exercise, lower back, muscle spasm, tenderness, naproxen, ibuprofen, acetaminophen, avoid activities, low-impact exercises, strengthening the core, improving flexibility, core strengthening exercises,