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msingh23

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Need assistance if this qualaify for a Detail or Comprehensive History on a New Patient for Orthopacedic visit.

Initial Orthopaedic Assessment

Employment: Accountant
Ref by: Myles

Vital Signs
Height: 67 inches
Weight: 200 pounds
Blood pressure: 160/80 mm Hg

History
CC: LBP
HPI: LBP for last 2 mos - had to carry a friend up 4 flights of stairs. Was sore the next day, some improvement initially but now getting sig LBP and spasm - unable to sit without pain, +pain w walk and stand. Pain getting progressively worse. Can't find a comfortable position. Deep achy LBP w some radiation to the buttock. Tried alleve and ibuprofen - not much help. No LE paresthesias, no change in B/B
No prior back injuries.
Played soccer and football in the past with no prior injury
PMH: none
PSH: none
FH: M heart disease
Other Medication List: alleve

DICLOFENAC SODIUM 75 MG TBEC (DICLOFENAC SODIUM) One by mouth every 12 hours
FLEXERIL 5 MG TABS (CYCLOBENZAPRINE HCL) One to two by mouth before bed

Allergies: No Known AllergiesPain site: lower back pain
scale: 8
Living environment: apartment, stairs

RISK FACTORS

Alcohol use: Y
Type: wine

Review of Systems
Constitutional: No Complaints
ENT: No Complaints
EYE: No Complaints
Gastrointestinal: No Complaints
Cardiovascular: No Complaints
Respiratory: No Complaints
Genitourinary: No Complaints
Neurological: No Complaints
Psychiatric: No Complaints
Endocrine: No Complaints
Hemato/Lymph: No Complaints.

Thanks for your assistance.
msingh23
 
msingh23 said:
Need assistance if this qualaify for a Detail or Comprehensive History on a New Patient for Orthopacedic visit.

Initial Orthopaedic Assessment

Employment: Accountant
Ref by: Myles

Vital Signs
Height: 67 inches
Weight: 200 pounds
Blood pressure: 160/80 mm Hg

History
CC: LBP
HPI: LBP for last 2 mos - had to carry a friend up 4 flights of stairs. Was sore the next day, some improvement initially but now getting sig LBP and spasm - unable to sit without pain, +pain w walk and stand. Pain getting progressively worse. Can't find a comfortable position. Deep achy LBP w some radiation to the buttock. Tried alleve and ibuprofen - not much help. No LE paresthesias, no change in B/B
No prior back injuries.
Played soccer and football in the past with no prior injury
PMH: none
PSH: none
FH: M heart disease
Other Medication List: alleve

DICLOFENAC SODIUM 75 MG TBEC (DICLOFENAC SODIUM) One by mouth every 12 hours
FLEXERIL 5 MG TABS (CYCLOBENZAPRINE HCL) One to two by mouth before bed

Allergies: No Known AllergiesPain site: lower back pain
scale: 8
Living environment: apartment, stairs

RISK FACTORS

Alcohol use: Y
Type: wine

Review of Systems
Constitutional: No Complaints
ENT: No Complaints
EYE: No Complaints
Gastrointestinal: No Complaints
Cardiovascular: No Complaints
Respiratory: No Complaints
Genitourinary: No Complaints
Neurological: No Complaints
Psychiatric: No Complaints
Endocrine: No Complaints
Hemato/Lymph: No Complaints.

Thanks for your assistance.
msingh23
Click to expand...

Location: LBP
Duration: last 2 mos
Severity: Pain getting progressively worse
Modifying Factors: Tried alleve and ibuprofen
Associated signs & symptoms: No LE paresthesias, no change in B/B
Quality: Deep achy LBP w some radiation to the buttock
Context: had to carry a friend up 4 flights of stairs

PMH: none (could include NKA)
PSH: none (could include employment status; use of alcohol;Played soccer and football; Living environment: apartment, stairs)
FH: M heart disease

ROS: 10 complete

HPI: COMPLETE
 
Thanks Tonyi for your detail response, for it will assist in other charts reviewing also,appreciated.
msingh23
 
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