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