Professional Documents
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E
Wheeze
Cardiovascular Pain Scale (Scale of 1-10; Lowest =1; Highest = 10)
Chest pain Left side 1 2 3 4 5 6 7 8 9 10
Diaphoresis Right side 1 2 3 4 5 6 7 8 9 10
Ankle edema
Syncope Onset Uncertain Gradual Sudden, without known injury
After an injury or accident Yes No Date __________________________
Gastrointestinal
Nausea or vomiting
Weight changes
Bowel dysfunction
Genitourinary
Hematuria
Dysuria
Bladder dysfunction
Musculoskeletal
Myalgias
Arthralgias
Joint swelling
Duration
Context PL
Work-related
Modifying Factors
Increased by
Decreased by
Unaffected by
Day
Night
Yes No Date reported to employer
Heat
Walking Climbing stairs
M
Recent trauma Pain Medications used for this problem
Range of Motion Over The Counter Ibuprofen Acetaminophen Other
limitations Prescription Ibuprofen Acetaminophen COX II Inhibitor Narcotics Steroids Muscle relaxer
Skin/Breasts
Masses Prior Evaluations or Treatments for this problem
New skin lesions Emergency Department Other Physician Physical Therapy
Sensitivity to sun Imaging None X-Ray Ultrasound MRI Bone Scan CAT Scan Lab tests EMG
Neurologic
SA
Seizures
Muscle weakness
Numbness Past Medical, Family Social History
Paresthesias Arthritis Heart disease HIV/AIDS Thyroid disease
Sexual dysfunction Asthma Valvular disease Malignancy Other
Endocrinologic COPD Hypertension Neuromuscular disease
Hair loss Diabetes Hepatic disease Renal disease
Polydipsia
Tremors ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
Neck pain Vaccines This patient is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella Tetanus
Heme/Lymph
Bleeding gums Surgeries
Unusual bruising Arthroscopy Hip Replacement Knee Replacement Other orthopedic surgery
Swollen lymph nodes CABG Carotid Endarterectomy Peripheral artery bypass Other surgery
Allergy/Immunology
Social History / Risk factors
Sinus problems No Yes Tobacco use ____ # Packs X ____ # Yrs
Recurrent infections No Yes Alcohol use ____ Drinks per day week
Psychologic No Yes Recreational drug use Inhalational Injectable Ingestible
Mood changes No Yes Drug dependence Narcotics Benzodiazepines
Agitation
Occupational History
Hallucinations
E
Extremities Within normal limits Cool Cyanotic Tender
Labs Lymphatics (2 areas must be examined)
Exam WNL Lymphadenopathy Areas examined Neck Axilla Groin Other
\____/ ____ / ____ / ____ / Musculoskeletal (4 areas must be examined)
/ \ \ \ \ Head and Neck
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Radiology
X-Ray
CT scan
Pain
Contractures
Stability
Inspection
Range of Motion
Pain
Contractures
Stability
PL
Strength and tone
Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Absent Present
WNL Dislocation Subluxation Laxity
WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
Spine, Ribs and Pelvis
WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
WNL Limited
Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Absent Present
WNL Dislocation Subluxation Laxity
MRI Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
M
Right Upper Extremity
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Ultrasound
Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Contractures Absent Present
Stability WNL Dislocation Subluxation Laxity
Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
SA
Other
Left Upper Extremity
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Additional Findings Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Contractures Absent Present
Stability WNL Dislocation Subluxation Laxity
Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
Right Lower Extremity
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Contractures Absent Present
Stability WNL Dislocation Subluxation Laxity
Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
Left Lower Extremity
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Contractures Absent Present
Stability WNL Dislocation Subluxation Laxity
Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
Exam continued on page 3
Neurologic
Coordination WNL Abnormal
Finger to Nose _______________________________________________________
Heel to Shin _______________________________________________________
Rapid Alternating Movements _______________________________________________________
Fine Motor Skills _______________________________________________________
_______________________________________________________
E
Deep Tendon Reflexes
Mental Status
Orientation Oriented to Person, Time and Place Disoriented to Person Time Place
Mood and Affect WNL Depressed Anxious Agitated