Osteopathic Center for Family Medicine

234 Main Street, Suite 100
Yarmouth, ME 04096
Tel: (207) 945-5400 | Fax: (207) 945-8300

ZZTest, Noah

DOB: 01/15/1985 (39 y/o)

Sex: Male

MRN: 00012345

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Progress Note
Date of Service: December 9, 2025 Visit Type: Office Visit - Established Physician: Leigh Forbush, DO
Subjective
Chief Complaint

Follow-up for hypertension management and new complaint of lower back pain for 2 weeks.

History of Present Illness

Patient is a 39-year-old male presenting for routine follow-up of essential hypertension, well-controlled on current medication regimen. He reports a new complaint of lower back pain that began approximately 2 weeks ago after helping a friend move furniture. Pain is described as dull and aching, located in the lumbar region, rated 5/10 at worst. Pain is aggravated by prolonged sitting and bending forward, relieved with rest and OTC ibuprofen. No radiation to legs, no numbness or tingling, no bowel or bladder changes. He has been taking ibuprofen 400mg as needed with moderate relief.

Review of Systems
Constitutional: Negative
HEENT: Negative
Cardiovascular: Negative
Respiratory: Negative
GI: Negative
GU: Negative
Musculoskeletal: Lower back pain as noted
Neurological: Negative
Psychiatric: Negative
Skin: Negative
Past Medical History
  • Essential hypertension I10
  • Hyperlipidemia E78.5
  • Obesity, BMI 32 E66.9
Surgical History
  • Appendectomy 05/01/1980
  • ORIF, right femur 05/01/1990
Family History
  • Father: HTN, MI at age 58, living
  • Mother: Type 2 DM, HTN, living
  • Siblings: Brother with HTN
Social History
Tobacco: Former smoker, quit 5 years ago (10 pack-year history)
Alcohol: Social, 2-3 drinks per week
Illicit Drugs: Denies
Occupation: Software engineer, sedentary work
Exercise: Walks 20-30 minutes, 3x/week
Current Medications
Medication Dose Frequency Route
Lisinopril 20 mg Once daily PO
Atorvastatin 20 mg Once daily at bedtime PO
Ibuprofen 400 mg PRN for pain PO
Allergies
Penicillin Reaction: Rash, hives
Sulfa drugs Reaction: GI upset
Immunizations
  • Influenza 10/15/2025
  • COVID-19 (Bivalent booster) 09/01/2024
  • Tdap 03/20/2022
Objective
Vital Signs
BP
128/82 mmHg
HR
72 bpm
RR
16 /min
Temp
98.4°F
SpO2
98% RA
Weight
215 lbs
Height
5'10"
BMI
30.9
Physical Examination
General: Well-appearing, no acute distress, pleasant and cooperative
HEENT: Normocephalic, PERRLA, oropharynx clear, TMs normal
Neck: Supple, no lymphadenopathy, no thyromegaly
Cardiovascular: RRR, no murmurs, rubs, or gallops. Peripheral pulses 2+ bilaterally
Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
Abdomen: Soft, non-tender, non-distended, normal bowel sounds
Musculoskeletal: Tenderness to palpation over L4-L5 paraspinal muscles bilaterally. Mild paraspinal muscle spasm noted. ROM lumbar spine limited by pain. Negative straight leg raise bilaterally. Normal gait. Full ROM of extremities.
Neurological: A&O x3, CN II-XII intact. DTRs 2+ and symmetric. Sensation intact to light touch L1-S1 dermatomes. Motor strength 5/5 bilateral lower extremities.
Skin: Warm, dry, no rashes or lesions
Assessment
Diagnoses
1. Acute lumbar strain S39.012A
2. Essential hypertension, well-controlled I10
3. Hyperlipidemia E78.5
4. Obesity E66.9
Differential Diagnosis
  • Lumbar disc herniation Less likely - no radicular symptoms
  • Lumbar facet syndrome Possible contributing factor
  • Sacroiliac joint dysfunction Less likely - pain midline
Plan
Medications
• Continue Lisinopril 20 mg daily for hypertension - well controlled
• Continue Atorvastatin 20 mg at bedtime for hyperlipidemia
• Start Cyclobenzaprine 10 mg TID PRN for muscle spasm × 7 days
• Continue Ibuprofen 400-600 mg q6h PRN with food × 7-10 days, then taper
Orders
• Lipid panel - due for annual monitoring
• CMP - routine monitoring on ACE inhibitor
• HbA1c - screening given family history and BMI
Procedures
• Osteopathic manipulative treatment (OMT) performed to lumbar spine - soft tissue, muscle energy, and counterstrain techniques. Patient tolerated well with immediate improvement in ROM.
Referrals
• Physical therapy referral for lumbar stabilization exercises if no improvement in 2-3 weeks
Patient Education
• Discussed proper body mechanics for lifting
• Provided stretching exercises for lumbar spine - handout given
• Heat application 15-20 minutes TID recommended
• Avoid heavy lifting and prolonged sitting for 1-2 weeks
• DASH diet reviewed for continued BP management
• Encouraged continued weight loss efforts - goal 10 lbs over next 3 months
Follow-Up
• Return in 2 weeks for back pain reassessment
• Return in 3 months for routine HTN/HLD follow-up and lab review
• Return sooner if back pain worsens, develops leg pain/numbness, or has difficulty with bladder/bowel function

Leigh Forbush, DO

NPI: 1790725497

Tel: (207) 945-5400 | Fax: (207) 945-8300

Osteopathic Center for Family Medicine

Electronically Signed

Signed: December 9, 2025 at 3:45 PM EST