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Subjective and Objective Examination for Billy

Patient Name/ Date of Birth: Patient Name/ Date of Birth: Billy The patient is a 48 year old male
insurance actuary.
Reason for referral: Evaluate and Treat
Medical Diagnosis/ Health Condition: LBP
Primary Language: English
Subjective Examination/ Patient Interview
Patient Goals: Able to walk without pain, able to stand for his sons games.
Personal Factors (Nutrition, Physical Activity/ Exercise Routine, Sleep): He enjoys golf and walking but isnt
doing either now due to his pain.
Environmental Factors: The patient is a heavy smoker and drinks moderately.
Body Chart: P1 moderate central low back pain. Constant and variable deep ache in the central lower back
that becomes sharp with fast walking.

Structures that underlie area of symptoms:


P1:

Structures that refer pain to the area of symptoms or


contribute to the area of pain:
P1:
Consider non-musculoskeletal structures that refer to
area of symptoms: P1:

STOP! A question for you: Based on the body chart what is your hypothesis/hypotheses?
Activity Limitations: (establish irritability)
Aggravating Factors:
1. Standing > 15 min inc. P1//decreases to a mild ache with sitting > 5 min.
2. Walking, especially rapid walking > 15 min avoids due to P1
3. Lying supine with legs straight immed. // settles OOP
Ease Factors: Sitting 5 min. improves pain to a mild ache.
24 hour: AM: worse; ease 15 OOB (out of bed); worse as the day progresses.

Subjective and Objective Examination for Billy


Subjective Examination/ Patient Interview (continued)
Current History: The patients complaints came on 3 weeks ago after standing at his sons baseball game. He
had pain at the game that worsened over the next day to his current levels. The patient reports that he is
improving but his wife suggested that he see a doctor to get checked out. X-rays were taken and showed mild
to moderate disc narrowing and degenerative changes at L4/5 and L5/S1. He is a heavy smoker and uses
moderate amounts of alcohol.

Past History: This is the fourth episode of this type in the past year for this patient. The first two episodes
were associated with prolonged standing and the third occurred upon waking. Each episode lasted about 4
weeks during which time he gradually improved by avoiding painful postures and activities.
Review of Systems (Body Structure/ Body Function Impairments)

Medications: Advil PRN


Diagnostic Tests: Consider your working hypothesis, what would be the diagnostic test most likely performed
on this patient?

Subjective and Objective Examination for Billy

Objective Examination Tests and Measures


Outcome Measures (Outcomes Scales): Not assessed
Activity Limitation/ Participation Restriction Measures:
Postural Control (Dynamic): Balance WNL
Mobility: Ambulatory without assistive device
Self-Care (ADLs and IADLs): Independent
Physical Impairment Measures/ Musculoskeletal
Observation of Posture (Supine, Sitting, Standing):
The patient is overweight, but not seriously obese, carrying most of his excess weight in his abdomen. He has
an increased lumbar lordosis, an increased thoracic kyphosis, with a forward head and rounded shoulders.
ROM:
F = Full ROM but with dev. to the (R) at midrange. At full flexion, the lumbosacral segment is rounded
instead of straight or concave.
During return to upright position, the patient extends the hips before extending the lumbar spine so
that he comes up with a rounded lumbar spine. At mid range, he bends the knees and helps come
upright with his hands on his thighs.
E= mod. limitation with increased P1
LSB =
RSB =
Strength (Resisted Motion, Positional Strength, MMT):
Muscle Length Testing (Flexibility): (+) Thomas test
Special Tests: Neurodynamic Testing: SLR to 95 deg bilaterally ; PKB ; (+) prone instability test, (+)
anterior instability test
Implication/ Clearing Tests: Hips SIJ
Palpation: L5 pain
Neurological:
Assessment after exam:

LS F: SQ LS E SQ, P1 slightly increased.