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Lower Back Pain

HISTORY:
Low back pain for  
Onset: , following  , 
Location: 
Radiation:  
Severity: ,  / 10
Impact on daily activities: , affecting 
Type: 
Pattern: , 
Worsening factors: 







Additional symptoms:
Treatments tried: , 
Occupation: 
Other elements:

EXAM:
Lower back:
- Inspection: 
- Palpation: 
- Range of motion: 
- Flexion: 
- Strength: lower extremities -R /5 , -L /5 
- Sensation: lower extremities -R , -L 
- Reflexes: patellar -R , -L , Achilles -R , -L 
- Special tests:
- Gait: 

ASSESSMENT:
 
DDx: 

PLAN:
- Lumbar X-ray
- CT scan of lumbar spine
- MRI of lumbar spine
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weights
- Physical therapy
- Heat or cold therapy
- 
- 
- 
- 
-  for  
- Referral to orthopedic surgeon
- Referral to pain management specialist
- Referral to rheumatologist
- Follow-up in  
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment