CC: Low back pain x 1 day HPI: 42 y/o male with acute LBP after lifting furniture. Left lumbar, aching, 6/10. Worse with bending/twisting. No radicular symptoms, no numbness/tingling, no bowel/bladder dysfunction.
Vitals: BP 132/82, HR 76 Spine: L4-L5 paraspinal tenderness L>R, limited flexion Neuro: Strength 5/5 bilateral LE, sensation intact, DTRs 2+, SLR negative
Primary Dx: Acute Lumbar Strain (M54.5) Clear mechanical mechanism, localized pain, no neurological deficits, negative red flags.
1. Activity modification x 2 weeks 2. Ice/heat 3. Ibuprofen 600mg TID x 7 days 4. Cyclobenzaprine 10mg TID PRN x 5 days Return if: Leg weakness, numbness, bowel/bladder changes