Lumbar Spine Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 50y/o complains of low back pain with radiation into right thigh. Pain has extended past the knee in the past, but does not currently. Pain is 3-7/10. Worse with prolonged walking and any bending or lifting. Pain is 60% low back, 40% thigh. No paresthesia's. No noted weakness. No bowel, bladder or sexual dysfunction. Pain is improved with bedrest. No night pain. no history of immunosuppressive medications. No cancer history. No other joint involvement. Previous treatment: NSAIDs, narcotic pain meds. no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: none
Flexion: 90
Extension: 30
Lateral Bend(R/L): 30 /30
Rotation (R/L): 45 / 45
L2 (iliopsoas / mid anterior thigh sensation)= 5/5 : normal
L3 (quadriceps / distal anterior thigh sensation)= 5/5 : normal
L4 (tibialis anterior / patellar reflex / medial ankle sensation)= 5/5 : 2+ : normal
L5 (EHL / dorsal foot sensation)= 5/5 : normal
S1 (Peroneals / Achilles reflex / lateral ankle sensation)= 5/5 : 2+ : normal
No quad tightness
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Seated SLR(R/L): - / -
Supine SLR (R/L): - / -
Dorsalis pedis (R/L): 2+ / 2+
Babinski reflex (R/L): - / -
Xray: Mild disk space narrowing. Mild facet arthropathy.
MRI: none
ASSESSMENT: Low Back Pain ()
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
AAOS info, McKenzie exercise program
NSAIDS
Follow-up 6-8 weeks