Lower Back Pain
HISTORY:
Low back pain for
Onset: , following ,
Location:
Radiation:
Severity: , / 10
Impact on daily activities: , affecting
Type:
Pattern: ,
Worsening factors:
Additional symptoms:
Treatments tried: ,
Occupation:
Other elements:
EXAM:
Lower back:
- Inspection:
- Palpation:
- Range of motion:
- Flexion:
- Strength: lower extremities -R /5 , -L /5
- Sensation: lower extremities -R , -L
- Reflexes: patellar -R , -L , Achilles -R , -L
- Special tests:
- Gait:
ASSESSMENT:
DDx:
PLAN:
- Lumbar X-ray
- CT scan of lumbar spine
- MRI of lumbar spine
- 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
- 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