Chief Complaint: Back Pain

Chief Complaint: Back Pain History of Present Illness This is a _____ yr-old (M/F) (with PMH sig ______) who presents with (sev______) (qual______) (mid/low) back pain (rad to ______) that began (gradually / suddenly) _____ (hrs/days/weeks) ago (when the patient was ______/ without any obvious inciting event). (The pain is worsened by ______and alleviated by ______.) (It has been asso. with ______.)

ROS PMH Const F/C Wt loss Reviewed CV CP Swell Syncope Resp SOB Cough Hemop GI AP Constip Meds GU Flank P Incont Renten Dysur  Reviewed Gyn VB Dc Changes OCPs Steroids Anticoag Skin Rash Musc P-claud Traum Falls a Surg Neuro Weak Numb Incont Saddle  Reviewed Recent procedures  All other systems reviewed/negative Risk factor assess: SH Vasc DVT/PE CT dz T/A-Ao CA/PVD  Occupation/functional status/housing ID DM CRF Immune IVDA  Tob, EtOH, drugs: IVDA, cocaine Neo Ca Hx

Exam  Const: VS (F/BP abn), (pain/no acute) distress  MS: Back nml to inspection. No focal  Resp: CTAB, nml effort, no retract. TTP, palpable step-offs, or deformities.  CV: Heart RRR, no MRG. No pulse deficits. SLR/CSLR neg. Flex/ext at hip & leg and  Abd: Soft. Nml bowel sounds, no bruit. dorsiflex of ankle & great toe 5/5 NT/ND. No peritoneal sn. No pulsatile or other strength bilat. Gait normal. masses. No CVAT. Nml rectal tone, no blood.  Neuro: Patellar and achilles reflexes  GU: Nml to inspection. Nml rectal tone & intact & symmetric. Heel-shin intact. sensation.  Psych: Appropriate affect. A&O to  Lymph: No cervical or extremity LAD. person, place and time.  Skin: No rashes, erythema, or induration. Orders Dx Tx UA Cx (U, B, S, W) IV, O2, Mon Pain: HCG Coag EKG Spasm: CBC Quant/T&C XR T/L Zofran Chem Bilat BPs CT T/L Abx Dimer PVR   ESR/CRP    Course Risk factor assess Tx/response/stability) Old recs Discussed/e-mailed Diagnosis: (Lumbar/Thoracic) Strain Sciatica Other: Plan: Early mobil Act mods Exercises NSAIDs Ultram Vicodin Valium Flexeril PCP f/u 5-7d MRI/Spine ref

Last Updated: 9/3/09 Differential  Traumatic o Vertebral fracture o Disc herniation (acute motor radiculopathy [multiple etiologies]) o Hematoma  Medical o Vascular . Thoracic aortic dissection . Abdominal aortic aneurysm . Pulmonary embolism o Infectious/inflammatory . Spinal epidural abscess . Vertebral osteomyelitis . Discitis . Transverse myelitis . Pyelonephritis . Sacroiliitis o Neoplastic . Spinal epidural metastasis (e.g., cauda equina) o Other . Nephrolithiasis . Spondylolisthesis

Lumbar Nerve Root Compression

Level/Root: L1-L3/L2,3 1. Motor Loss: hip flexors 2. Sensory Loss: ant thigh 3. Reflex: none

Level/Root: L3-L4/L4 1. Motor Loss: quad/tib ant 2. Sensory Loss: ant knee, med calf 3. Reflex: patellar

Level/Root: L4-L5/L5 1. Motor Loss: dorsi flexion toes (EDL,EHL), gluteus medius 2. Sensory Loss: lat calf/dorsal foot great toe 3. Reflex: none

Level/Root: L5-S1/S1 1. Motor Loss: gastroc/soleus peronei, gluteus maximus 2. Sensory Loss: post calf/lat foot & heel, 4&5 web 3. Reflex: ankle jerk

Last Updated: 9/3/09 Level/Root: S2-S4/S2-4 1. Motor Loss: bowel/bladder 2. Sensory Loss: perianal 3. Reflex: cremaster

Last Updated: 9/3/09