Chief Complaint
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Have you had any trauma to your back?
Old carts for HPI
What are the events surrounding the start of your back
...
Chief Complaint
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Have you had any trauma to your back?
Old carts for HPI
What are the events surrounding the start of your back pain?
What are the events surrounding the start of the pain in your leg(s)?
When did the pain in your back start?
Does the pain in your back radiate someplace else? Where?
Where more precisely is the pain in your leg(s)?
Where more precisely is the pain in your back?
Does the pain in your back come and go?
What does the pain in your back feel like?
Do you have pain when lifting?
Does anything make the pain in your back better or worse?
How severe (1-10 Scale) is the pain in your back?
PMH, FH, SH as Needed
Any new or recent change in medications?
Are you taking any over the counter or herbal medications?
Do you have any allergies?
Review of Systems (ROS)
Do you have problems with heat or cold intolerance, increased thirst, increased sweating,
frequent urination, or change in appetite?
Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness,
tingling, or tremor?
Do you have problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers,
or night sweats?
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When you urinate, have you noticed any pain, burning, blood, difficulty, starting or stopping,
dribbling, incontinence, urgency during day or night, or any changes in frequency?
Do you have any problems with headaches that don’t go away with aspirin or Tylenol
(acetaminophen), double or blurred vision, problems hearing, ear pain, sinus problems, chronic
sore throats, or difficulty swallowing?
Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your
vomit, dark tarry stool. Bright red blood in your bowel movements, early satiety, or bloating?
Assessment
Vitals: Temperature, Pulse, Respiration, BP, Mental Status
Breast: Breast Exam
Heart: Auscultate heart
Chest wall & Lungs: Auscultate lungs
Abdomen: Palpate Abdomen
Musculoskeletal: Inspect/palpate back and spine, test range of motion, test strength
Neurological: Assess gait & stance, Reflexes: Deep tendon and Plantar/Babinski
(L5/S1), Sensory tests
Key Findings
Acute onset LBP radiating down right leg following lifting tables: MSAP
RLE sensory deficit: RELATED
RLE motor deficit: RELATED
Hyporeflexia: right patellar tendon: RELATED
Positive right straight leg raising (SLR) test; positive contralateral SLR: RELATED
Asthma: UNRELATED
Hypertension: UNRELATED
Osteoporosis: UNKNOWN
Postmenopausal status: total abdominal hysterectomy with bilateral salpingo-oophorectomy
(TAH BSO): UNKNOWN
40 pack year history of smoking: UNKNOWN
History of systemic steroid use: UNKNOWN
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