Right back and hip pain: 

 
- Endorses pain at right low back and right hip 
- Onset approximately 1 month ago
- Denies known inciting event 
- Describes pain as sharp at times and aching at other times
- Progressively improves throughout the day, significantly worse upon waking in the morning  
- Sleeps on right side during the night 
- Walking improves the pain
- Works as Call Center Operator for Community Health, sedentary
- No heat or ice application attempted
- Taking Tylenol and Ibuprofen which helps temporarily 
- Similar symptoms earlier this year, improved with PT
- Severity 8/10 at its worst, currently 3/10
- Pain does not radiate 
- No new exercise or activity 
- Participates in chair exercises 3 times weekly for past year; hopes to participate in yoga twice
weekly but has not yet started again 
- Pain does not wake patient from sleep
- Denies trauma, falls
- Denies fever, rash, swelling, erythema, bruising or other skin changes
- Denies urinary or bowel incontinence or paresthesia
- Denies weakness or numbness

1. Chronic right-sided low back pain without sciatica

- Prior imaging as above
- No red flag signs or symptoms at this time, neurologically intact, ambulating well
- Recommend supportive care including over the counter pain relief as needed, topical pain
relief, application of heat or cool
- Recommend gentle stretches and activity as tolerated
- Recommend healthy diet and weight loss 
- Ambulatory Referral to Physical Therapy; Future
- Discussed red flag signs and symptoms warranting immediate evaluation by physician, patient
understands and agreeable to plan of care 

ROV: As needed for persistent or worsening symptoms, otherwise as scheduled