Consultation Date: Patient’s name: Date birth: Dear Dr. Thank you for referring this -- years old ="right| left" handed "gentleman| lady" to pain care Clinic at -- site for chronic pain assessment and management. HISTORY OF PRESENTING COMPLAINT/S "His| her" main complaint is -- The pain resulted from -- and patient has had this pain for the past -- and reports symptoms of pain described as "constant| off and on| intermittent"] pain with characters of "dull|achy|sharp|shooting|burning|tingling|cramping|codness|numbness". The pain radiates to --. The symptoms are worsened by -- and relieved by --. DN4 Score: On an NRS scale the pain rating is -- at its worst, -- at best. on average it is -- and currently the pain is --. Fibromyalgia Rapid Screening Tool: -- is suggestive of|not suggestive of| diagnosis of fibromyalgia. Total BPI Interference Score is -- With respect to the patient’s complaint of back pain, the patient reports no bowel or bladder dysfunction. There is no saddle anaesthesia, weakness or radiation reported. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V. drug use, chronic steroid use or substantive night pain. With respect to the patient’s complaint of neck pain the patient reports no paresthesia, weakness or radiation. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V drug use, chronic steroid use or substantive night pain. The patient’s headache is not associated with nausea, vomiting, photophobia, or phonophobia. There are not reported visual changes or aura. No history of syncope, seizure or head injury. No fever/chills or signs of systemic infection. No history of hypertension. There are no indications of medication overuse headache. CONSULTATIONS Other Healthcare Professionals: PAST MEDICAL HISTORY 1. Surgical: 2. Medical: FUNCTONAL INQUIRY General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints. PREVIOUS INVESTIGATIONS PAST PAIN MEDICATIONS CURRENT MEDICATIONS ALLERGIES Medications: NKDA/ Environmental: Nil SOCIAL HISTORY The patient is currently "single| married| widow| common law| divorced" Presently living: The patient has -- children. "He| she" "is Currently on Disability and has been so since| patient is currently unemployed and has been so since| patient is retired| was working as" The patient’s highest level of education completed is --. PSYCHOLOGICAL STATUS AND RELATED MATTERS There is no| is history of suicidal ideation and the patient has had no| had|previous suicide attempts. The current suicide risk is low| moderate| high. His anxiety score is --. and depression score is --. The patient does not see| sees a psychiatrist. Smoking: "non smoker| Ex-smoker| current smoker" Alcohol: "not a drinker| social drinker| heavy drinker" Illicit drug: "denies using the drug| social user| on medical cannabis| current user" Sexual function is reported "unimpaired| is adversely affected|both desire and physical ability are reduced by pain/medication"]. "he|she"] is "unconcerned| concerned"] about this issue. Sleep is generally "refreshing| un-refreshing". There "is no| is" latency in sleep onset with "no| frequent"] interruptions due to the pain. The patient reports "no awakening| awakening every". Medication "is not| is"] utilized as a sleep aid. ADDICTION RISK 1.Worsening AM pain: None/ Yes 2.Alcohol: None/ Yes 3. Nicotine smoker none/ yes 4.Prescription drugs: Off the street: No/ Yes. Borrowed: No/ Yes. 5.Family psychiatric history: None/ Yes 6.Family History of substance abuse: None/ Yes 7.History of trauma: Emotional: No/ Yes; Physical: No/ Yes; Sexual: No/ Yes 8.Which of the following recreational or street drugs has the patient used? None/ Yes 9.Has the patient ever received treatment for drug abuse? No/ Yes. Urine Drug Screen: OXY "neg| pos" TCA: "neg| pos" AMP: "neg| pos" MOP: "neg| pos" BZO: "neg| pos" MTD: "neg|pos" BAR: "neg|pos"] MAMP: "neg| pos" COC: "neg|pos" THC: neg| pos PHYSICAL EXAMINATION Age: Female| male Right-handed| left-handed BP: HR: Weight: Height: BMI: On physical exam today, I found the patient to be alert and cooperative, well oriented to person, place and time. Patient communication skills, recent and remote memory, insight and judgment. affect and mood appeared are within normal limits. Body Type is "normal| overweight| obese and appears conditioned/ unconditioned. Gait is "normal| antalgic| shuffling| wide base"] with "upright| mildly kyphotic| kyphotic| stooped forward"] posture Head and Face Exam: Power is normal bilaterally| weak bilaterally| weak right side| weak left side. Sensation to light tough is intact| decreased. Palpation: non tender. |reveled tenderness over"] Neck Exam: Inspection of the neck and cervical spine: Palpation: no tenderness/ tenderness over spinous process and paraspinous muscles. Cervical range of motion: normal/reduced Strength: within normal limits| revealed weakness. Spurling test: negative/ positive Cervical compression test: negative| positive Light touch of face and neck: did not reveal| allodynia, hypoesthesia. Shoulder Exam: Inspection of both exposed shoulders from front and back: normal/ asymmetry Apprehension test for shoulder stability: negative bilaterally| positive right or left side. On palpation: did not elicit tenderness| caused tenderness over" There is no tenderness / tenderness over the spinous process and paraspinous muscles. Range of motion performed actively and passively: normal / reduced Strength: within normal limits| revealed weakness over Speed test negative| positive over right shoulder| was positive over left shoulder"]. Neer's test negative| positive over right shoulder| was positive over left shoulder"]. Hip Exam: Inspection of hip from front and back: normal| antalgic| wide base| normal with slow get up and go gait. Had no asymmetry or atrophy| some asymmetry noted over| atrophy noted over"]. Palpation: "did not illicit tenderness| caused tenderness over| were not tender but patient reported pain on deep palpation of"]. Range of motion: normal / reduced. strengths examination "within normal limits bilaterally| revealed weakness bilaterally| revealed weakness left side| revealed weakness right side"]. Sensation: normal / reduced. Lower Back Exam: Inspection of entire back: Palpation for areas of tenderness="did not cause tenderness.| tenderness over" Range of motion performed in forward flexion, extension, and lateral bending: normal / reduced Strength testing "Did not show any weakness| showed weakness over right side| showed weakness over left side| showed weakness bilaterally" Neurologic exam of deep tendon reflexes over knee and ankle normal and symmetric| Straight-leg raise is ="negative| positive ="Bilaterally| Right side| Left side" Negative babinski sign. Sensation over L4, L5, S1, Obturator and Femoral nerve distributions ="are within normal limits| showed decreased sensation over"] There is no| is allodynia, Hypoesthesia or Hyperesthesia over lower extremities. Distal pulses of dorsalis pedis and posterior tibialis = palpable| palpable but weak| not palpable SI joint pain: bilaterally| over left side| over right side.
There are 0 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 1102 boilerplate words
Send Feedback for this SOAPnote
You must be logged in to post a comment.