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Lbp Observation

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Lbp Observation
Reason for Visit: LBP Vital Signs - B/P: Temp: Pulse: Resp: O2 Sat
S: LBP, next orthopedic appointment on 2/24/2017, he’s been taking acetaminophens, but it is not managing his pain. His plan is to contact the work man’s comp RN to move the appointment sooner.
O: antalgic gait, mild grimace facial expression noted; limited lumbar spine range of motion related to pain; CN II- CN XII grossly intact; On inspection no muscle atrophy noted; Normal reflexes, + 5 strength to lower and upper extremities, +3 pulses to pedal and pedal
A: Chronic LBP
P:
ICE X 20 minutes NOW
ESI X 1 Week
Disposition: Return to restrictive duty per ortho; Follow up with ortho
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