Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of adolescent idiopathic scoliosis (AIS) involving the thoracic spine. Onset noted by [parent/patient] at age [age], with progressive postural asymmetry. Denies radicular pain, numbness, weakness, or bowel/bladder dysfunction. No history of trauma or systemic symptoms. Current Risser sign [0-5] and menarchal status [pre/post] noted.
Clinical Examination Findings
Physical exam reveals thoracic prominence on the [right/left] side during Adam’s forward bend test. Scapular asymmetry noted. No café-au-lait spots or cutaneous stigmata of dysraphism. Neurological exam: motor strength 5/5 in all extremities, symmetric deep tendon reflexes, negative Babinski, and no clonus. Gait is steady and non-antalgic.
Treatment Protocol
Treatment plan: [Observation/Bracing/Surgical Consultation]. For observation: serial radiographs every [4-6] months to monitor Cobb angle progression. For bracing: [TLSO/Milwaukee] brace prescribed for [X] hours/day. Physical therapy initiated for core strengthening and postural stabilization. Follow-up scheduled in [X] months.