Low Back Pain follow-up
Age: years old
Gender:
HISTORY:
Returns for a low back pain follow-up
Last visit was ago
Progress since last visit:
Updates on symptoms:
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, up to °, over
, over
Physical activity changes: ,
Medication tried: , , , , , , ,
Injections: , , ,
Physical therapy: ,
Chronic pain program:
X-ray:
CT scan:
MRI:
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
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-
-
-
- for
Further care:
- Referral to orthopedic surgeon
- Referral to pain management specialist
- 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: EXAM: Low back: ASSESSMENT: PLAN: