Back pain ADN

Acute/Chronic(> 12 weeks) back pain
HPI
Onset: •
Activity at onset: •
Location of pain: •
Radiation: •
Quality: •
Provoking factors: •
Alleviating factors: •
Neuropathic symptoms: • 
Core 
Red flags: ALL NEGATIVE
   -Weakness: No
   -Loss of bowel control: No
   -Inability to void: No
   -Fevers: No
   -Immunocompromised: No
   -Prev history of cancer: No
   -Prev history of IVDU: No
 »«YES - Pt requires urgent imaging with MRI!
   
Yellow Flags
   -Do you think your pain will improve or worsen?
   -Do you think you would benefit from activity,movement or exercise?
   - How are you emotionally coping with your back pain?
   - What treatments or activities do you think will help you recover?


O:
Gait: antalgic«, otherwise normal»«, •»
L-spine: No SEADs, pain with palpation of • 
Flexion: •
Extension: •
Lateral flexion: •
Rotation: •

Root  Strength (L/R)    DTR (L/R)    Light touch 
L2:       5/5  5/5                              Intact              
L3:       5/5  5/5                              Intact
L4:       5/5  5/5           2+  2+          Intact
L5:       5/5  5/5                              Intact
S1:       5/5  5/5           2+  2+          Intact

S2/S3: deferred to due to lack of clinical concern
Babinski: «negative»
SLR: «positive»«ipsilateral pain»«negative»

A: «Back-dominant»«Leg-dominant» mechanical back pain; likely •
P: 
Reassurance that symptoms improve in 1-2 weeks
Conservative mgmt while acute: heat, massage, stretching (demonstrate or handout given), staying active
Physiotherapy consult if no improvement in 1-2 weeks
«Imaging not indicated at this time»
«Rx given: •»
Advised of red flags; f/u if no improvement after physio or PRN