Back exam

by Mark Morgan on April 1, 2010BACK: 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*** Gait is ***antalgic/moves slowly/normal/unable to walk on heels and toes/normal heel and toe walking strength*** 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***. 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***. Deep tendon reflexes patellar and achilles are ***not performed/normal bilaterally/normal bilaterally except for --- at ---***. 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*** 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***. 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---***.

in Musculoskeletal