|
HPI
|
|
|
Severity*
|
Onset: *
• • •
|
|
Moderate. Gradual. No injury. No other symptoms
|
Course*
• • •
|
|
Chronic pain. sx are similar to prior episodes.
|
Fever?
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
MSK (positive)
• • •
|
MSK (negatives)
• • •
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
NECK: +cervical paraspinus TTP. no midline TTP
|
+ trapezius TTP
|
|
Neck (positive)
• • •
|
Neck (negative)
• • •
|
|
Additional Neck FIndings
|
PE: Head to toe exam (abd deferred)
|
|
PE: Superficial
|
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
MDM
|
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
