BUDDHAS PALM THERAPY SERVICESS.O.A.P. NOTES

DIAGNOSIS: ____________________ CASE: LUMBAGO

Client’s Name: _FITZGERALD M PACHECO_______________________ Contact #: ______358 - 86 - 88_________

Address: _PACHECO VELASQUEZ TONDO MANILA___________________ Age: ________33_____

E-mail add: pacheco_peter67@yahoo.com__ Sex: _M Date of Birth: _12/22/1980_ Occupation: MASSAGE THERAPIST

Emergency Contact: __CECIL IA A. SAUZA__________________ Phone: _______358 – 86 - 88______________

Date of Client intake: _____APRIL 10, 2014__________________________

Subjective: “SUMASAKIT ANG LIKOD KO”

Objective:

VITAL SIGNS:

BP: 120/80 mmhgPR: 85 bpmRR: 18 cpmT: 37 C

VISUAL ASSESSMENT:

(+) Spasm on the lower back

(+) Fullness of soft tissue on the lower back

PALPATION:

(+) Hyperthermic on the lower back(+) Trigger points on the lower back(+) Nodules on the lower back(+) Tenderness on the lower back(+) Spasm on the lower back(+) Tightness on lower back

ROM:

(+) Limitation of motion on hip joint upon flexion

SENSORY ASSESSMENT:

(+) pain on the lower back (P/S 8/10)

ASSESSMENT: PROBLEM LIST

1. Pain on the lower back (P/S 8/10)2. Spasm on the lower back3. Fullness of soft tissue on the lower back4. Hyperthermic on the lower back5. Trigger points on the lower back6. Nodules on the lower back7. Tenderness on the lower back8. Spasm on the lower back9. Tightness on lower back10. Limitation of motion on hip joint upon flexion

PLAN GOALS: LONG TERM / SHORT TERM

Long Term:

To eliminate the pain within 4 treatment session

Short Term:

To reduce pain in every treatment session

MASSAGE THERAPY MANAGEMENT:

1. Apply hot compress to the lower back for 10 minutes2. Apply effleurage to the lower back 3x3. Apply petrissage to the lower back 3x4. Apply friction (crossfiber) to the lower back