Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of adolescent idiopathic scoliosis (AIS). Notable for [Right/Left] thoracic/lumbar curvature noted by [parent/school screening/PCP]. Denies radicular pain, numbness, weakness, or bowel/bladder dysfunction. No history of trauma. Family history positive for scoliosis in [mother/father/sibling]. Risser sign status [0-5].
Clinical Examination Findings
General: Patient is in no acute distress. Spine: Adam’s forward bend test positive for [Right/Left] rib hump. Shoulder height asymmetry noted. Scapular prominence [present/absent]. Pelvic tilt [neutral/tilted]. Neurological: Gait is steady, motor strength 5/5 in all extremities, DTRs 2+ symmetric, no pathological reflexes (Babinski/Clonus). Skin: No café-au-lait spots or hairy patches noted.
Treatment Protocol
Treatment plan: [Observation/Bracing/Surgical Consultation]. If bracing: TLSO brace prescribed for [X] hours per day. Physical therapy initiated for core stabilization and postural awareness. Follow-up imaging (standing PA/Lateral scoliosis series) scheduled in [X] months to monitor Cobb angle progression.