Musculoskeletal & Rheumatology
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(**Draft)


MAINTANANCE & MONITORING:
Date:
Indication:
Opioid Prescribed:
Daily Dose:
Daily Morphine Equivalent:

Goals Achieved: to make the patient feel better, to reduce pain intensity (30%), to improve mood and fuction
Pain Intensity (VAS):
- Pain worst:
- Pain least:
- Pain average:
- Pain right now:
Functional Status (Brief Pain Inventory):

Adverse Effects:
- Nausea: 0=none, 1=yes, 2=Limits ADLs, 3=Prevent ADLs
- Constipation:
- Drowsiness:
- Dizziness/Vertigo:
- Dry Skin/Pruritus:
- Vomiting:
- Other:
Complications:
Aberrant Behaviour: yes,
Urine Drug Screening:
Other Medications:
Assessment and Plan:
Other Comments:


Withdrawal Symptoms:

Early symptoms of withdrawal include:
- Agitation
- Anxiety
- Muscle aches
- Increased tearing
- Insomnia
- Runny nose
- Sweating
- Yawning

Late symptoms of withdrawal include:
- Abdominal cramping
- Diarrhea
- Dilated pupils
- Goose bumps
- Nausea
- Vomiting

Treatment: clonidine 0.1mg PO TID prn
(**Draft)


MAINTANANCE & MONITORING:
Date:
Indication:
Opioid Prescribed:
Daily Dose:
Daily Morphine Equivalent:

Goals Achieved: to make the patient feel better, to reduce pain intensity (30%), to improve mood and fuction
Pain Intensity (VAS):
- Pain worst:
- Pain least:
- Pain average:
- Pain right now:
Functional Status (Brief Pain Inventory):

Adverse Effects:
- Nausea: 0=none, 1=yes, 2=Limits ADLs, 3=Prevent ADLs
- Constipation:
- Drowsiness:
- Dizziness/Vertigo:
- Dry Skin/Pruritus:
- Vomiting:
- Other:
Complications:
Aberrant Behaviour: yes,
Urine Drug Screening:
Other Medications:
Assessment and Plan:
Other Comments:


Withdrawal Symptoms:

Early symptoms of withdrawal include:
- Agitation
- Anxiety
- Muscle aches
- Increased tearing
- Insomnia
- Runny nose
- Sweating
- Yawning

Late symptoms of withdrawal include:
- Abdominal cramping
- Diarrhea
- Dilated pupils
- Goose bumps
- Nausea
- Vomiting

Treatment: clonidine 0.1mg PO TID prn
Result - Copy and paste this output: