Musculoskeletal Symptom Evaluation

Code from chart · WRK-017

Clinical chart

Signed note

Signed encounter note

DOS · 2026-10-26Assignment · WRK-017Setting · Outpatient physician office

Reason for visit

Evaluation of low back pain.

Interval history

Pain remains in the lower back and does not radiate into either leg. No numbness, tingling, or weakness is reported.

Examination

Lower lumbar tenderness is present. Strength, sensation, and reflexes are intact; gait is steady.

Assessment and plan

Low back pain without sciatica. No structural cause is established at this visit. Recommend activity as tolerated, heat, and short-term conservative care.

Coding workbench

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Diagnosis codes

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