Lumbar spine

{Lumbar spine}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[-] back pain
[-] back stiffness

Right lower limb symptoms:
[-] pain
[-] sensory loss
[-] paraesthesia
[-] weakness
[-] wasting
Distribution:

Left lower limb symptoms
[-] pain
[-] sensory loss
[-] paraesthesia
[-] weakness
[-] wasting
Distribution:

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Management to date:
-

Diagnostic investigation results:
[+] 
[~] 
[-] 
[?]

PAST MEDICAL HISTORY
Relevant past medical history:
[-] significant low back pain
[-] sciatica
[-] lumbar radiculopathy
[-] lumbar surgery
[-] spondyloarthritis
[-] leg length inequality

FAMILY HISTORY
[-] spondyloarthritis

PHYSICAL 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: 
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.
  Right:
    5 : hip flexion - L2-4 
    5 : hip extension - S1 
    5 : knee extension - L2-4 
    5 : knee flexion - L4-S2 
    5 : ankle dorsiflexion - L4-L5 
    5 : ankle plantar flexion - S1 
  Left:
    5 : hip flexion - L2-4 
    5 : hip extension - S1 
    5 : knee extension - L2-4 
    5 : knee flexion - L4-S2 
    5 : ankle dorsiflexion - L4-L5 
    5 : ankle plantar flexion - S1

Deep tendon reflexes: 
Reflex grading: 0 = no response, 1 = decreased, 2 = normal, 3 = increased, 4 = increased with clonus, N = not testable.
  Right:
    2 : knee jerk - L2, L3, L4 
    2 : ankle jerk - S1, S2 
    2 : plantar reflex - L5, S1, S2 
  Left:
    2 : knee jerk - L2, L3, L4 
    2 : ankle jerk - S1, S2 
    2 : plantar reflex - L5, S1, S2

Sensation: (Light touch, pin-point) 
Sensory grading (compare with the face as the normal control): 
0 = absent (anaesthesia), 1 = altered or reduced, 2 = normal.
  Right:
    2 : L1 - iliac crest and inguinal region 
    2 : L2 - antero-lateral thigh 
    2 : L3 - knee 
    2 : L4 - medial lower leg, medial malleolus 
    2 : L5 - medial tibia, great toe and medial dorsum of foot 
    2 : S1 - sole and lateral side of foot 
    2 : S2 - calf and posterior thigh to buttock 
    2 : S3-5 - buttock, perianal 
  Left:
    2 : L1 - iliac crest and inguinal region 
    2 : L2 - antero-lateral thigh 
    2 : L3 - knee 
    2 : L4 - medial lower leg, medial malleolus 
    2 : L5 - medial tibia, great toe and medial dorsum of foot 
    2 : S1 - sole and lateral side of foot 
    2 : S2 - calf and posterior thigh to buttock 
    2 : S3-5 - buttock, perianal

Slump sign: {abnormalities}
[-] left
[-] right

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260131]

Lumbar spine

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