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HPI
|
|
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Pain radiates to: ___
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Location:
• • •
|
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Onset: *
• • •
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Non-radiating pain
|
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Course*
• • •
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Severity*
|
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Fever?
|
Pain is worse with movement but better with rest*
|
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Pt denies any numbness or tingling.
|
|
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No b/b changes
|
Pt denies any weakness
|
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No hx of IVDA
|
Sx are similar to prior episodes.
|
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Additional notes
|
No hx of cancer
|
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|
|
|
REVIEW OF SYSTEMS
|
|
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Positive findings (MSK)
• • •
|
Negative findings (MSK)
• • •
|
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Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
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PHYSICAL EXAM
|
|
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Back: +lumbar paraspinus TTP. no midline TTP
|
Back: negative. Neck: negative.
|
|
Positive findings (Back)
• • •
|
Negative findings (Back)
• • •
|
|
NEURO: No paresthesias to BUE
|
|
|
Additional
|
|
|
PE: Superficial
|
PE: Head to toe exam
|
|
Insert PE Macro
|
|
|
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
DDx: Strain vs radiculopathy vs herniation
|
MDM Notes
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
|
|
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DISCHARGE
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home DUC ONLY
|
Discharge Note: ERD ONLY
|
