Lumbosacral Spine Examination Detailed
Lumbosacral Spine Examination (Detailed) [comment memo="Detailed back examination (for New level 3 or established level 4)"] [select value="Casual|Well|Disheveled"] <-- General appearance [select value="Male|Female"] <-- Sex [select value="None|Mild|Moderate|Severe"] <-- Distress level [select value="x4|x3|x2|x1|x0"] <-- Alert and oriented Vital signs (pulse, respirations, and blood pressure) were taken and placed in the confidential medical chart. [select value="None|Hyperlordotic|Flattened"] <-- Lordosis [select value="No|Yes"] <-- Deformity Skin inspection [text size="100" default="There was *** erythema/ecchymosis present at ***."] Tenderness to palpation [text size="100" default="Upon palpation, there was *** tenderness over the ***."] Spasm/Guarding [text size="100" default="No Spasm/Guarding present at *** level."] Range of motion [text size="100" default="Range of motion (in degrees): Flexion: ***, Extension: ***, Side bend left: ***, Side bend right: ***."] [select value="Negative|Positive|Contralateral Positive"] <-- Straight leg examination [select value="Normal strength|Deficit"] <-- Bilateral lower extremity strength [select value="Normal sensation|Abnormal sensation"] <-- Bilateral lower extremity sensation [select value="Normal reflexes|Abnormal reflexes"] <-- Bilateral lower extremity reflexes [select value="Normal|Abnormal"] <-- Bilateral lower extremity vascular exam [select value="Normal|Abnormal Heel Walk|Abnormal Toe Walk|Both abnormal"] <-- Heel and Toe walk [select value="Normal|Abnormal"] <-- Gait [select value="Normal sensation and tone|Abnormal sensation and/or tone"] <-- Pelvic/rectal exam Additional notes [text size="100"][/html][/conditional]
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