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Back Exam
Mar 31, 2010
•
Mark Morgan
categories:
Musculoskeletal & Rheumatology
Objective/Exam
Short Version
BACK: normal curvature: no localized tenderness. Full ROM. ***normal curvature/increased lordosis/dorsal kyphosis/no tenderness or muscular spasm/no bony tenderness/range of motion limited at ---***
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Long Version
BACK: The spine was examined by palpation and inspection and revealed ***normal vertical with concave curves at cervix and lumbar vertebrae, normal gait and posture, no tenderness or muscular spasm/lordosis/kyphosis/legs same length/legs are unequal/nontender spine/tenderness along ---/no muscle spasm/muscle spasm/full range of motion/limited range of motion in ---/positive leg lifting test/negative leg lifting test/findings on physical examination do not support symptoms as described by patient***
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BACK: The spine was examined by palpation and inspection and revealed ***normal vertical with concave curves at cervix and lumbar vertebrae, normal gait and posture, no tenderness or muscular spasm/lordosis/kyphosis/legs same length/legs are unequal/nontender spine/tenderness along ---/no muscle spasm/muscle spasm/full range of motion/limited range of motion in ---/positive leg lifting test/negative leg lifting test/findings on physical examination do not support symptoms as described by patient***
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Gait is ***antalgic/moves slowly/normal/unable to walk on heels and toes/normal heel and toe walking strength***
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Forward flexion ***fingertips to thighs/fingertips to knees/fingertips to midtibia/fingertips to ankles/fingertips to feet*** produces ***pain/no pain***. Lateral bending to left at *** degrees produces ***pain/no pain***. Lateral bending to right at *** degrees produces ***pain/no pain***. Extension of back ***produces no pain/worsens the same pain/relieves the pain/worsens pain on left paraspinal at L4L5/worsens pain on left paraspinal at L5S1/worsens pain on right paraspinal at L4L5/worsens pain on right paraspinal at L5S1/worsens pain on left paraspinal in general/worsens pain on right paraspinal area in general/worsens pain on both sides/worsens pain in right SI joint/worsens pain in left SI joint***.
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Palpation of the back produces ***no pain/paraspinal pain in lumbar area/paraspinal pain in thoracic area/paraspinal pain in thoracolumbar area/bilateral paraspinal pain/midline pain over spinous processes/pain at L4L5 on the left/pain at L5S1 on the left/pain at L4L5 on the right/pain at L5S1 on the right/pain at the left SI joint superiorly/pain at the left SI joint inferiorly/pain at the right SI joint superiorly/pain at the right SI joint inferiorly***.
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Deep tendon reflexes patellar and achilles are ***not performed/normal bilaterally/normal bilaterally except for --- at ---***.
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LE sensation shows ***normal to light touch/decreased light touch sensation in left L5/decreased light touch sensation in right L5/decreased light touch sensation in left S1/decreased light touch sensation in right S1***
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Strength on knee flexion and extension is ***without weakness/mildly weak/moderately weak*** and foot inversion, eversion, and great toe dorsiflexion shows ***no weakness/left/right*** ***weakness on foot inversion/weakness on foot eversion/weakness on great toe dorsiflexion***.
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Hip testing: ***Hip int and ext rotation without pain and no palpable pain in SI joints/Hip internal and external rotation produces pain in the SI joint/Hip internal and external rotation produces pain in the buttocks ---on the left side/on the right side---***.
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display/hide references
reference: Based on template by Stephen P. Merry, MD, MPH, Consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
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