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anggand@aol.com

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Pt is a well developed female. Inspection of her spine reveals she has diminished lordosis. Palpation reveals tenderness a the midline and paraspinal areas. Very limited. She can not go into full extension but can go into almost complete flexion. Deep tendon reflexes are symetrical in the upper and lower extremities. Sensation is intact. Normal strength. Tenderness at the SI joint and trochanteric bursae with pain on flexion, abduction and external rotation. There are obvious surgical sites where the acoustic neuromas were with deficits at that area. Surgery is well healed. Mild tenderness to palpation of the head. Straight leg raising is positive bilaterally. Flexion, abduction and external rotation positive for thigh pain and groin pain.
 
anggand@aol.com said:
Pt is a well developed female. Inspection of her spine reveals she has diminished lordosis. Palpation reveals tenderness a the midline and paraspinal areas. Very limited. She can not go into full extension but can go into almost complete flexion. Deep tendon reflexes are symetrical in the upper and lower extremities. Sensation is intact. Normal strength. Tenderness at the SI joint and trochanteric bursae with pain on flexion, abduction and external rotation. There are obvious surgical sites where the acoustic neuromas were with deficits at that area. Surgery is well healed. Mild tenderness to palpation of the head. Straight leg raising is positive bilaterally. Flexion, abduction and external rotation positive for thigh pain and groin pain.
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What have you got so far? This looks like a musc and neuro exam to me. I'd probably use the 1997 exam guidelines on this one, without scoring it out myself I'd probably use either musc or neuro template.
 
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