Lumbosacral Spine Examination Detailed

Musculoskeletal & Rheumatology, Objective/Exam Elements
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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]
Lumbosacral Spine Examination (Detailed)
Detailed back examination (for New level 3 or established level 4)
<-- General appearance
<-- Sex
<-- Distress level
<-- Alert and oriented
Vital signs (pulse, respirations, and blood pressure) were taken and placed in the confidential medical chart.
<-- Lordosis
<-- Deformity
Skin inspection

Tenderness to palpation

Spasm/Guarding

Range of motion

<-- Straight leg examination
<-- Bilateral lower extremity strength
<-- Bilateral lower extremity sensation
<-- Bilateral lower extremity reflexes
<-- Bilateral lower extremity vascular exam
<-- Heel and Toe walk
<-- Gait
<-- Pelvic/rectal exam
Additional notes
[/html][/conditional]
Result - Copy and paste this output:

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