Sinai-Grace Internal Medicine Residency
Ambulatory Clinic Documentation Guides
Low Back Pain
·
History
- Acute
or chronic? Onset?
- Pain scale, type of pain, any
aggravating or relieving factors, radiation of pain, mechanical vs.
non-mechanical pain, any change with sitting, standing, flexion or
extension of spine, h/o trauma.
- Alarm symptoms- age>50, night
pain, bowel/bladder dysfunction, motor weakness, h/o IVDA, h/o cancer and
wt loss.
- Any
stiffness and other joint involvement?
- Occupation
of the patient (past and present).
- Any signs/symptoms of depression?
- Narcotic
and non-narcotic pain medications used in the past.
- Any
other pain relieving measures used?
- Any
worker’s compensation, legal issues and disability involving back pain?
·
Physical Exam –Involves mainly detailed examination of lower extremities
- Inspection –Gait, movement, any
muscle atrophy, fasciculations, curvatures of
the spine.
- Palpation- Vertebral, paraspinal muscle or sacroiliac joint tenderness
- Neuromuscular exam –SLR, Crossed SLR
- Great toe and ankle dorsiflexion-L4,
L5
- Knee reflex L2- L4
- Ankle reflex L5-S2
- Hamstring reflex
- Adductor reflex L2-L4
- Power in all muscle groups
- Sensory exam-dermatomal,
rectal, perianal sensations.
- -Light touch, vibration, and joint
position
- Range of motion of the spine,
flexion, extension, lateral rotation, and lateral flexion.
·
Investigations- To be done if indicated
- X-ray
–for pts with alarm symptoms and for chronic LBP
- CCP,
CBC, Alk phos, ESR,
Urine and serum electrophoresis
- CT/
MRI of the spine