Chronic Pain
HISTORY:
Chronic pain for
Location:
Onset: , following
Severity: , / 10
Impact on daily activities:
Type:
Radiation:
Pattern: , worse during the
Episode duration:
Worsening factors:
Treatments tried: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: weight: kg, height: cm, waist: cm, BMI:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , ,
- X-ray of affected areas
- MRI of affected areas
- Nerve conduction studies
- EMG
- Encourage regular exercise
- Heat or cold therapy
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- Physical therapy
- Occupational therapy
- Cognitive behavioral therapy
- Referral to pain management program
- Referral to pain management specialist
- Referral to rheumatologist
- Referral to physical medicine specialist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment