Lumbar Spine

#Lumbar Spine S: Subjective Presenting Complaint: (-) back pain (-) back stiffness (-) other/s -> Right lower limb symptoms: (-) pain (-) sensory loss (-) paraesthesia (-) weakness (-) wasting Distribution: Left lower limb: (-) pain (-) sensory loss (-) paraesthesia (-) weakness (-) wasting Distribution: Symptom development: - Onset: - Variation: - Aggravating factors: - Relieving factors: Past Medical History: (-) significant low back pain (-) sciatica (-) lumbar radiculopathy (-) lumbar surgery (-) spondyloarthritis (-) leg length inequality (-) other -> Family History: (-) spondyloarthritis O: Objective Examination: Spine: (-) deformity (-) scoliosis (-) kyphosis (-) flat lumbar lordosis (-) pronounced lumbar lordosis (-) spinous process tenderness (-) paraspinal tenderness (-) scars Paraspinal muscle spasm: (-) right (-) left Muscle wasting: (-) Right thigh (-) Right calf (-) Left thigh (-) Left calf Active ranges of motion: **abnormalities** (-) Flexion [60+] (-) Extension [25+] (-) Lateral flexion [25+] (-) Rotation [30+]: Right Motor power: **abnormalities** Motor power grading: 0 = no contraction, 1 = slight contraction and no movement, 2 = active movement with gravity eliminated, 3 = active movement against gravity only, 4 = active movement against resistance but reduced, 5 = normal active movement against resistance, NT = not testable. Right: (-) hip flexion (L2-4) (-) hip extension (S1) (-) knee extension (L2-4) (-) knee flexion (L4-S2) (-) ankle dorsiflexion (L4-L5) (-) ankle plantar flexion (S1) Left: (-) hip flexion (L2-4) (-) hip extension (S1) (-) knee extension (L2-4) (-) knee flexion (L4-S2) (-) ankle dorsiflexion (L4-L5) (-) ankle plantar flexion (S1) Deep tendon reflexes: **abnormalities** Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus, NT = not testable. Right: (-) knee jerk (L2, L3, L4) (-) ankle jerk (S1, S2) (-) plantar reflex (L5, S1, S2) Left: (-) knee jerk (L2, L3, L4) (-) ankle jerk (S1, S2) (-) plantar reflex (L5, S1, S2) Sensation: (Light touch, pin-point) **abnormalities** Sensory grading (compare with the face as the normal control): 0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal. Right: (-) L1 (iliac crest and inguinal region) (-) L2 (antero-lateral thigh) (-) L3 (knee) (-) L4 (medial lower leg, medial malleolus) (-) L5 (medial tibia, great toe and medial dorsum of foot) (-) S1 (sole and lateral side of foot) (-) S2 (calf and posterior thigh to buttock) (-) S3-5 (buttock, perianal) Left: (-) L1 (iliac crest and inguinal region) (-) L2 (antero-lateral thigh) (-) L3 (knee) (-) L4 (medial lower leg, medial malleolus) (-) L5 (medial tibia, great toe and medial dorsum of foot) (-) S1 (sole and lateral side of foot) (-) S2 (calf and posterior thigh to buttock) (-) S3-5 (buttock, perianal) Slump sign: (-) left (-) right Investigation Results: A: Assessment Clinical Summary: Diagnosis / DDx: P: Plan Investigations Requested: Treatment: Referrals: Patient Education / Home Care Advice: Review:

Copy | Print | Help

Related Items

• None