Ht 5’7", Wt 192lbs, BP 98/66 Sitting (+1)
Constitutional: General Appearance: healthy-appearing and NAD. (+1)
Psychiatric: Orientation: oriented to time, place, and person. Mood and Affect: active and alert.(+2)
Gait and Station: Appearance: limp and antalgic gait and ambulating with no assistive devices.(+1)
Cardiovascular System: Arterial Pulses Right: posterior tibialis normal and dorsalis pedis normal. Arterial Pulses Left: posterior tibialis normal and dorsalis pedis normal. (+1)
Skin: Lumbosacral Spine: normal skin. (+1)
Lumbar Spine: Inspection: no induration, ecchymosis, or swelling and normal alignment. Bony Palpation of the Lumbar Spine: no tenderness of the spinous process or the sacrum. Bony Palpation of the Right Hip: no tenderness of the iliac crest, the SI joint, or the greater trochanter. Bony Palpation of the Left Hip: tenderness of the SI joint and the greater trochanter and no tenderness of the iliac crest. Soft Tissue Palpation on the Right: tenderness of the iliolumbar region. Soft Tissue Palpation on the Left: tenderness of the paraspinal region at L 5 and the iliolumbar region. Active Range of Motion: some limitation of lumbar motion.(+2)
Motor Strength: L1 Motor Strength on the Right: hip flexion iliopsoas 5/5. L1 Motor Strength on the Left: hip flexion iliopsoas 5/5. L2-L4 Motor Strength on the Right: knee extension quadriceps 5/5. L2-L4 Motor Strength on the Left: knee extension quadriceps 5/5. L5 Motor Strength on the Right: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. L5 Motor Strength on the Left: ankle dorsiflexion tibialis anterior 5/5 and great toe extension extensor hallucis longus 5/5. S1 Motor Strength on the Right: plantar flexion gastrocnemius 5/5. S1 Motor Strength on the Left: plantar flexion gastrocnemius 5/5.(+1)
Neurological System: Ankle Reflex Right: normal (2). Ankle Reflex Left: normal (2). Knee Reflex Right: normal (2). Knee Reflex Left: normal (2). Sensation on the Right: normal distal extremities. Sensation on the Left: normal distal extremities. Special Tests on the Right: seated straight leg raising test negative. Special Tests on the Left: seated straight leg raising test negative.(+2)