Back pain
Age: years old
Gender:
HISTORY:
Presents with a - history of low back pain
Onset was , started
Location is
Radiation to
Rated at / 10
Impact on daily activities is , affecting
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Associated symptoms: *Try using right-click for negatives*
, , ,
, up to °, over
, over
Contributing factors:
no history of: , , , , ,
no use of:
EXAM:
Low back:
Inspection:
Palpation:
Range of motion:
- Flexion:
- Extension:
- Right bending:
- Left bending:
- Right rotation:
- Left rotation:
Strength: throughout lower extremities, except on
Sensation: throughout lower extremities, except on
Reflexes: throughout lower extremities, except on
Special tests:
- Straight leg raise:
- Crossed straight leg raise:
- Tripod:
- Faber test:
Gait:
ASSESSMENT:
DDx: lumbar strain, lumbar sprain, disc herniation, lumbar radiculopathy, lumbar spondylosis, spinal stenosis, cauda equina syndrome, vertebral fracture, ankylosing spondylitis, metastatic cancer to the spine, epidural abscess, pyelonephritis, kidney stones, ruptured abdominal aortic aneurysm
PLAN:
Investigations:
- Lumbar X-ray
- CT scan of lumbar spine
- MRI of lumbar spine
Treatments:
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
-
-
- for
Further care:
- Referral to orthopedic surgeon
- Referral to pain management specialist
- Referral to rheumatologist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Low back: ASSESSMENT: PLAN: