Low Back Injury
Age: years old
Gender:
HISTORY:
Presents with a low back pain following an injury ago
Mecanism of injury:
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, lumbar fracture, sacral fracture, disc herniation, lumbar radiculopathy, lumbar spondylosis, spinal stenosis, cauda equina syndrome, osteoporotic vertebral fracture, pelvic fracture
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
- Follow-up in
- Return if pain worsens or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Low back: ASSESSMENT: PLAN: