MSK – Pain | CLINIBORG

HISTORY: provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

NECK: no complaints pain stiffness spasm burning localized radiation to shoulder radiation to deltoid radiation to UE

UP/MID BACK: no complaints interscapular pain trap spasm

CHEST/ABD: no complaints pain w breathing bruising

LOW BACK: no complaints pain stiffness spasm burning localized radiation to buttocks radiation to thigh radiation to LE

UE:

no complaints pain swelling deformity bruising

LE:

no complaints pain swelling deformity bruising

STATED CAUSE: old new injury MVA fall near-fall assault sports work fall direct blow crush jam turning lifting abduction hyperflexion repetitive injury unknown

PREVIOUS EVALUATION/TREATMENT: denies previous work-up ER UC XR CT PCP DC PT extensive evaluation injections surgery medication therapy improved with previous management unchanged with previous management medication partially helps medication doesn't help

HPI: mild moderate severe increasing in severity remaining constant decreasing in severity occasional frequent constant dull stabbing sharp burning pounding numbing shooting affected by sitting affected by bending/turning affected by straining/coughing worse AM worse during day worse HS interfere with ADL interfere with sleep causing depression

PAIN SCALE:

PMSH: head injury back pain migraine chronic pain meds obesity diabetes

SOCIAL HISTORY: current smoker former smoker (h/o) substance use

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

objective fever subjective fever chills
EYES:

change in vision photophobia periorbital swelling pain with EOM
EARS:

pain bleeding tinnitus decreased in hearing
NOSE:

discharge snoring bleeding
MOUTH/THROAT:

toothache sore throat odynophagia dysphagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure dyspnea orthopnea ankle swelling ankle discoloration leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing rib pain cough
GI:

poor appetite nausea vomiting abdominal pain constipation diarrhea
GU:

dysuria hematuria hesitancy retention incontinence inguinal swelling genital lesion/discharge
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness sensory-motor loss bowel/bladder dysfunction
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia autoimmune dz h/o cancer
DERM:

dryness pruritus rash redness swelling wounds bruising

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Appearance:
well-appearing alert allows exam no distress noted while getting on/off exam table & walking around exam room poor cooperation with exam guarding ill-appearing drowsy appears impaired slumped

Skin: warm, dry grossly intact no bruises normal turgor tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Head/Face: normocephalic no evidence of trauma symmetrical face non-tender CN grossly intact

Eyes: clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora periorbital swelling dysconjugate gaze

Ears: symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or blood TMs normal in appearance

Nose: nares patent bilaterally septum midline mucosa pink & moist mucosal edema clear discharge

Mouth/Throat: normal voice moist oral mucosa without lesions or injury patent pharynx w/o swelling or exudates hoarseness tooth decay upper denture lower denture pharyngeal erythema w/o exudates pharyngeal crowding tonsillar enlargement

Neck: symmetric with free painless ROM no LAD anterior LAD posterior LAD DROM paracervical muscle spasm

Chest/Lungs: normal work of breathing, symmetrical chest expansion clear and equal breath sounds bilaterally chest wall atraumatic and non-tender poor effort

CV: regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen: not examined normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG

GU: not examined no suprapubic tenderness no CVAT bilaterally normal external genitalia

MSK - inspected, observed in active ROM, & palpated:

no gross deformity or misalignment normal color joints above and below affected area intact good ROM for age demonstrated very limited range of motion deformity swelling tenderness pain with axial loading DROM muscle spasm trigger points joint laxity skin intact abrasion laceration bruise

Neuro: oriented to person, place, time normal speech normal concentration and attention memory grossly intact ambulates w/o limp or alteration in gait balance & coordination grossly intact extremities strong w/o atrophy, tremor or fasciculations normal sensory exam of upper and lower extremities normal motor function of upper and lower extremities heel/toe walk without difficulty seated SLR negative bil antalgic gait wide gait shuffling gait deliberate gait

Behavior: calm pleasant respectful cooperative with exam exam limited by urgency exam limited by poor cooperation exam limited by safety concerns guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric demanding particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity: no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech: clear & coherent normal rate & rhythm slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats

Thought Process: organized/linear/logical circumstantial tangential perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting delusions paranoid ideation

OFFICE X-RAYS:

essentially normal no fx staff to notify patient once radiology report becomes available

DX: headache concussion loss of consciousness cervical pain cervical radiculitis/neuritis trapezius sprain/strain thoracic pain thoracic disc displacement/herniation chest wall pain lumbar pain lumbar sprain/strain lumbar disc displacement/herniation lumbar DDD sciatica shoulder pain elbow pain wrist pain hip pain knee pain foot pain bursitis tenosynovitis TMJ pain disturbed sensation-paresthesia peripheral nerve entrapment multiple somatic complaints myofascial pain subjective pain syndrome anxiety insomnia secondary to pain status post alleged injury secondary to MVA secondary to slip and fall

PLAN OF CARE: patient/family verbalized understanding of dx and POC, agreed with dx and POC did not agree with dx and POC, encouraged to seek second opinion

GOALS: conservative rehabilitation for 12-15 weeks to include passive and active therapy, along with orthopedic modalities promote interventions emphasizing patient responsibility, therapeutic exercise / stretching at home, early return to work, cognitive restructuring Detailed ortho / neuro examination by chiropractic will consider specialty evaluation (ortho, neurology, pain management, neurology) if not responding to above follow up w PCP to address chronic health issues

ORDERS - MA: injection dsg procedure none

TREATMENT: provided with crutches provided with splint/brace provided with sling provided with compression bandage/sleeve

ORDERS - RX: OTC electronic paper given to MA to be transmitted to pharmacy non-NSAID to control pain/headache anti-inflammatory to control soft tissue inflammation and pain antispasmodic to decrease muscle hypertonicity and improve sleep opioid pain medications for short term relief of extreme pain patient declined none

ORDERS - LABS: CBC CMP TSH A1C Lipids PSA FOBT/FIT UA HIV, RPR, HCV, GC, CT UDS none

ORDERS - IMAGING: X-ray US MRI none

ORDERS - REFERRALS: none ortho PT neurology deferred none

ORDERS - FORMS: excuse accomodations clearance return to school/work school/participation physical none

COORDINATION OF CARE
REVIEWED: MA notes med list previous visits PMP/CURES previous laboratory studies previous diagnostic studies specialty reports hospital discharge

DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, previous visits laboratory/diagnostic studies specialty consults hospital visits xray findings medications PMP reporting medication side effects immediately medication compliance NSAIDs prn ROM exercise/stretching to prevent deconditioning cognitive restructuring in managing chronic conditions symptom exacerbation through rebound mechanism risks of respiratory depression with polypharmacy

DISCHARGE CONDITION/SAFETY: improved stable unchanged no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

DISPOSITION: home advised to use UC for acute non-emergent problems advised of immediate need for further ER evaluation and treatment declined emergency transfer elected private transportation to ER left exam room before visit conclusion was asked to leave clinic

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, here in-person televisit 24 hours 1 2-3 5-7 10-14 30 60 90 days weeks months f/u acute episode f/u labs f/u imaging f/u new/changed rx f/u specialty consult

BARRIERS TO CARE: language barrier socio-cultural factors poor effort/cooperation with exam incomplete history history not supported by findings vague complaints supporting documentation unavailable failed to obtain old records failed to complete referrals or testing multiple comorbidities and/or polypharmacy multiple providers/prescribers multiple drug/treatment intolerance/failure frequent ER/UC visits frequent office contacts poor compliance with POC negative attitude to proposed tx lack of interest in non-drug tx overreliance on short-acting meds overwhelming focus on Rx drugs poor insight lack of motivation dependent attitude preoccupation with illness unhealthy coping mechanisms somatization catastrophization pessimism overgeneralization unrealistic health beliefs psych comorbidity anxiety depression alcohol or substance use social or occupational dysfunction secondary gain hostile/disruptive behavior affect none noted at this time

MSK – Pain

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