Chronic Pain follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a chronic pain follow-up

Location is on ‍rightleft ‍ ‍generalizedlow back

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Update on the pain:

Rated at ‍012345678910 / 10 ‍

Impact on daily activities: ‍minimal

Described as ‍crampingburning

Radiation ‍none to ‍

Pattern ‍constantintermittent

Episodes last for ‍ ‍, recur ‍ times per ‍

Worsening factors: ‍noneactivityrest ‍



Associated symptoms: *Try using right-click for negatives*

‍pain

‍stiffness

‍numbness

‍tingling

‍weakness

‍difficulty walking

‍loss of bowel control

‍loss of bladder control

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍fever, up to ‍°, over ‍ ‍hoursdays

‍unexplained weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths



Physical activity changes: ‍noneincreased low-impact exercises, ‍effectiveineffective

Medication tried: ‍none, ‍NSAIDs, ‍ibuprofen, ‍acetaminophen, ‍topical analgesics, ‍effectiveineffective, ‍adverse effect, ‍good adherence

Injections: ‍none, ‍corticosteroid injections, ‍hyaluronic acid injections, ‍effectiveineffective

Physical therapy: ‍noneongoingcompletednot interested, ‍effectiveineffective

Chronic pain program: ‍completedenrolledabandonednot interested ‍



X-ray: ‍

CT scan: ‍

MRI: ‍





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Cervical spine: ‍tenderness on ‍, range of motion ‍fulllimited

Shoulder: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Elbow: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Wrist: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Hand: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Lumbar spine: ‍tenderness on ‍, range of motion ‍fulllimited

Hip: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Knee: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Ankle: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Foot: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought ‍organized, ‍suicidal ideation, judgment ‍good





ASSESSMENT:

‍Chronic Pain ‍likelysuspectedpossible, ‍adequately controlled

DDx: fibromyalgia, osteoarthritis, rheumatoid arthritis, lupus, ankylosing spondylitis, spinal stenosis, herniated disc, neuropathy, diabetic neuropathy, postherpetic neuralgia, trigeminal neuralgia, cancer-related pain, endometriosis, irritable bowel syndrome, migraine, tension headache, depression, anxiety, somatoform disorders, myofascial pain syndrome, complex regional pain syndrome, post-surgical pain, post-traumatic pain, chronic pelvic pain, chronic abdominal pain





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP, ‍ESR, ‍creatinine, ‍TSH, ‍calcium, ‍phosphate, ‍albumin, ‍ferritin, ‍vitamin D, ‍uric acid, ‍CK, ‍LFTs

- X-ray of affected areas

- MRI of affected areas

- Nerve conduction studies

- EMG

Treatments:

- Education on chronic pain

- Encourage regular exercise

- Heat or cold therapy

- ‍Acetaminophen

- ‍NSAIDs

- ‍Opioids

- ‍Antidepressants

- ‍Anticonvulsants

- ‍Topical Analgesics

- Physical therapy

- Occupational therapy

- Cognitive behavioral therapy

Further care:

- Referral to pain management program

- Referral to pain management specialist

- Referral to rheumatologist

- Referral to physical medicine specialist

- Follow-up in ‍ ‍weeksmonths

- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment