West Virginia > Workers Comp
Low Back Examination BI-LBE - West Virginia
| Low Back Examination Form. This is a West Virginia form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
BI-LBE 01/06 Low Back Examination T O B E C O MP L E T E D BY T H E P H Y S I C I A N. Patient name: SSN: Date of Injury: Date of Birth: Claim Number : Date of Exam: Please check one or more: Claim Reopening Consultation 1. Inspection (standing) YES 1.1 Patient stands unassisted 1.2 Scoliosis 1.3 Antalgic lean(Asymmetry) 1.4 Lumbar Hypolordosis 1.5 Lumbar Hyperlordosis Other observations: 2. Palpation (standing, seating, or prone) YES 2.1 Vertebral tenderness/restriction 2.2 Coccyx tenderness (external palpation) US E BL A CK IN K Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV, 25332-3151 HT. WT. Pulse BP Rasp. Physician: Address: Phone: FEIN: Impairment Rating Independent Examination 120-day Examination Comprehensive Examination NO NO L1 L2 L3 L4 L5 2.3 Sacral base & pelvis level (standing) Left YES 2.4 Paraspinal muscle tenderness 2.5 Paraspinal muscle spasm 2.6 Sacroiliac joint tenderness 3. Gait 3.1 Limp Yes No 3.2 Assistive devices (cane, brace, prosthesis) 3.3 Other observations 4. Squat 4.1 Squats fully and rises without difficulty Comments 5. Range of Motion (standing)* 5.1 Sacral Flexion 5.2 Sacral Extension 5.3 Forward bending (Flexion) 5.4 5.5 5.6 5.7 Backward bending (Extension) Left side bending Right side bending Comments ° ° ° ° ° ° Yes No (Inclinometer required for impairment examinations) WNL Yes Pain No Restriction Left Right Explain: NO Right YES NO RANGE OF MOTION CERTIFICATION Thoracolumbar motion testing is valid if the following four criteria are achieved. Please certify the status of the examinee on each of these four criteria: · The back injury is now stable. Yes No · The motions were not curtailed due to a report of pain, fear of injury, or neuromuscular inhibition. Yes No · Three consecutive measurements of each motion were within 5° (within 10° if the three averaged 50° or more) Yes No · Examinee passed validity test. Yes No Physician's Signature Source: AMA Guides to the Evaluation of Permanent Impairment, pp. 112 & 127. 5.8 Inclinometer *NOTE: Subtract sacral motions from T12 motions (pp.3/126-129 AMA Guides, 4th ed.) BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com Patient's Name Date of Exam Claim Number Page 2 6. MOTOR STRENGTH (standing, walking, seated, or supine) NORMAL ABNORMAL 6.1 Hip flexion 6.2 Hip extension 6.3 Hip abduction 6.4 Knee extension 6.5 Knee flexion 6.6 Ankle dorsiflexion 6.7 Ankle planter flexion 6.8 Great toe extension 6.9 Heel toe walk 6.0 Toe walk GRADE (OUT OF 5) LEFT RIGHT 7. SENSORY (pin prick) (seated or supine) LEFT Normal 7.1 L3 sensory 7.2 L4 sensory 7.3 L5 sensory 7.4 S1 sensory 7.5 Comments Diminished Absent Normal RIGHT Diminished Absent 8. REFLEXES (seated) Patellar Achilles Other (+2normal) 8.1 Left 8.2 Right 8.3 Left 8.4 Right 0 0 0 0 +1 +1 +1 +1 +2 +2 +2 +2 +3 +3 +3 +3 clonus clonus clonus clonus USE BLACK INK 9. STRAIGHT LEG RAISING (sitting) (0-90° scale) (Measure knee extension) 9.1 Left 9.2 Right ° ° Pain: Pain: Yes Yes No No Location of Pain: Location of Pain: Back Back Same Leg Same Leg Contralateral back/leg Contralateral back/leg 10. HIP AND SACROILIAC TESTS 10.1 Hip test pain 10.2 Sacroiliac test pain Yes Yes No No Left Left Right Right 11. STRAIGHT LEG RAISING (supine) (0 -90° scale) 11.1 Left 11.2 Right ° ° Pain: Pain: Yes Yes Left Dorsalis Pedis Present? Yes No No No Location of Pain: Location of Pain: Right Yes No Back Back Same Leg Same Leg Contralateral back/leg Contralateral back/leg 12. PULSES 12.1 12.2 12.3 Posterior tibial Present? Yes No Yes No Other observations (Clubbing, Cyanosis) __________________________________________________________ 13. MUSCLE MEASUREMENT 13.1 13.2 Left Thigh Left Calf Right Thigh Right Calf cm below tibial tubercle cm below tibial tubercle 14. LEG LENGTH EXAM 14.1 Symmetrical 14.2 Shorter Difference of cm Yes Left Right No Right cm Not Tested Supine Left Standing cm Standing: measure from greater trochanter to floor Supine: measure from anterior superior iliac spine to medial/lateral malleolus. American LegalNet, Inc. www.USCourtForms.com Patient's Name Date of Exam Claim Number Page 3 OTHER TESTS AND FINDINGS 16. CLINICAL IMPRESSION OF SOMATIC AMPLIFICATION SENSORY EXAMINATION: RESPONSE TO PINPRICK 16.1 No deficit or deficit well localized to dermatome(s) Deficit related to dermatome(s) but some inconsistency Nondermatomal or very inconsistent deficit Blatantly impossible (i.e., split down midline of entire body with positive tuning fork test) 16.2 AMOUNT OF BODY INVOLVED <15% 0 15 -35% 1 36-60% 2 >60% 3 (check) (check) (check) SCORE MOTOR EXAMINATIONS 16.3 No deficit or deficit well localized to myotome(s) Deficit related to myotome(s) but some inconsistency Nonmyotomal or very inconsistent weakness, exhibits cogwheeling or giving away, weakness is coachable Blatantly impossible, significant weakness which disappears when distracted 16.3 AMOUNT OF BODY INVOLVED <15% 0 15 -35% 1 36-60% 2 >60% 3 TENDERNESS 16.5 No tenderness or tenderness localized to anatomically sensible structure Tenderness not well localized, some inconsistency Diffuse or inconsistent tenderness, multiple structures (skin, muscle, bone, etc.) Impossible, significant tenderness of multiple structures (skin, muscle, bone, etc.) which disappears when distracted 16.6 AMOUNT OF BODY INVOLVED <15% 0 15-35% 1 36-60% 2 >60% 3 DIFFERENTIAL STRAIGHT LEG RAISING (SLR) 16.7 The difference between SLR tests performed in the supine and sitting positions (the patient is distracted in the sitting position by examining the bottom of his/her feet). Example: supine SLR positive at 10°, seated SLR positive 50°, difference = 40° Difference <20° 0 20 -45° 1 >45° 2 No pain seated, but strongly positive SLR when supine at less than 45° 3 USE B L A CK I N K (check) (check) (check) (check) TOTAL SCORE 17 . C O M M E NT S American LegalNet, Inc. www.USCourtForms.com Patient's Name Date of Exam Claim Number Page 4 18. RADIOGRAPHIC EXAM Yes No Date Type (Plain, CT, MRI, Myelogram) Findings(Attach report if available): Patient Position During X-ray: Recumbent Weight Bearing Unknown 19. CLINICAL DIAGNOSIS (Please indicate appropriate ICD-9 code(s) and give written description. Generic diagnoses are printed for your convenience; you may substitute other diagnoses. If appropriate, multiple diagnoses can be designated.) SOFT TISSUE Lumbar sprain/strain (847.2) Lumbosacral sprain/strain (846.0) Sacroiliac sprain/strain (846.1) D
|
|||||||
