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Back Pain Assessment/Plan
Apr 13, 2010
•
Mark Morgan
categories:
Assessment & Plan
Musculoskeletal & Rheumatology
Assessment:
Lumbago
Lower Back Pain
Lower Back Spasm
Plan:
Ibuprofen 400 mg three times a day with food as needed for pain
Naproxen 500 mg three times a day with food as needed for pain
Acetaminophen 650 mg four times daily as needed for pain
Discussed heat and ice massage
Flexeril 10 mg nightly as needed for pain/spasm (sedation side effect discussed)
Discussed postural exercises such as walking/swimming 3 times a week for 40 minutes
Discussed stretching and strengthening exercises and staying active
If no improvement in next week, call or return to clinic for Physical Therapy referral
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