Reason for Visit: s/p 14 ESI Visit; LBP
Vital Signs - B/P:122/74 Temp: Pulse: 89 Resp:18 O2 Sat 99 %
S: TM completed total of 14 ESI visit, and he is here for LBP follow up. TM rates his pain at 2/10 and intermittent shooting pain to his left mid-thigh level. TM denies tingling or numbness in his lower extremities, loose of movement, weakness, or loss of bowel and bladder control. TM reports chronic LBP, previous injury to the lower back, doesn’t recall when or how.
O: On inspection of Lumbar Spine: No discoloration, no muscle atrophy, no edema noted at the Lumbar Spine area. Lumbar Spine Tenderness with palpation over Left lumbar region; CN II- CN XII grossly intact; Normal reflexes, + 5 strength to lower and upper extremities, +3 pulses
Vital Signs - B/P:122/74 Temp: Pulse: 89 Resp:18 O2 Sat 99 %
S: TM completed total of 14 ESI visit, and he is here for LBP follow up. TM rates his pain at 2/10 and intermittent shooting pain to his left mid-thigh level. TM denies tingling or numbness in his lower extremities, loose of movement, weakness, or loss of bowel and bladder control. TM reports chronic LBP, previous injury to the lower back, doesn’t recall when or how.
O: On inspection of Lumbar Spine: No discoloration, no muscle atrophy, no edema noted at the Lumbar Spine area. Lumbar Spine Tenderness with palpation over Left lumbar region; CN II- CN XII grossly intact; Normal reflexes, + 5 strength to lower and upper extremities, +3 pulses