Lumbar Spine Exam

General Appearance: mild distress.  The patient is able to ambulate well.  The gait IS antalgic.
Straight leg raising is positive on the right for radicular symptoms.
Sensory exam in the legs is normal/is abnormal.
Knee reflexes are normal and symmetric\
Strength is normal and symmetric
Paraspinal muscle spasm: Noted moderate midline 
There is no midline tenderness.
ROM of spine reduced/flexion-extension and rotation
General Appearance: mild distress. The patient is able to ambulate well. The gait IS antalgic.
Straight leg raising is positive on the right for radicular symptoms.
Sensory exam in the legs is normal/is abnormal.
Knee reflexes are normal and symmetric\
Strength is normal and symmetric
Paraspinal muscle spasm: Noted moderate midline
There is no midline tenderness.
ROM of spine reduced/flexion-extension and rotation

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 64 boilerplate words
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: