TPI main

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Subjective

[TPI follow-up for treatment of pain in area of chief complaint. Document the patient's chief complaint and history of present illness. Include details such -as symptom description, onset, duration, location, aggravating and relieving factors, associated symptoms, -Relevant negatives, and any relevant lifestyle or systemic -Information. For example, describe pain characteristics, functional limitations, and any relevant vital sign reports or systemic symptoms.] The pain has had some flare-ups, but the level has been significantly improved since TPI started. -Contraindications Reviewed: 1-No active infection at injection site 2-No bleeding disorder 3-Not on anticoagulation or antiplatelet therapy (or cleared if applicable) 4-No known allergy to local anesthetic

Subjective

[TPI follow-up for treatment of pain in area of chief complaint. Document the patient's chief complaint and history of present illness. Include details such -as symptom description, onset, duration, location, aggravating and relieving factors, associated symptoms, -Relevant negatives, and any relevant lifestyle or systemic -Information. For example, describe pain characteristics, functional limitations, and any relevant vital sign reports or systemic symptoms.] The pain has had some flare-ups, but the level has been significantly improved since TPI started. -Contraindications Reviewed: 1-No active infection at injection site 2-No bleeding disorder 3-Not on anticoagulation or antiplatelet therapy (or cleared if applicable) 4-No known allergy to local anesthetic

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Objective

[Recognize the chief complaint. If it is lumbar or hip pain, use the following **Inspection:** - (No other deformities or scoliosis) - No scar - No swelling - Lumbar lordosis: (normal, increased or decreased) - No other side involvement - Palpation: - Lumbar spine Range of Motion (ROM): - Hip ROM: - Neurological Findings: - Light touch sensation is normal -Knee reflex (Normal ( 2+ symmetric), Hyporeflexia or hyperreflexia) [Recognize the chief complaint. If it is shoulder pain, use the following:] Inspection: No atrophy, deformity, or asymmetry. Palpation: Tenderness ( mild, moderate, or severe) (over the subacromial space, pectoral region, supraspinatus, deltoid or subdeltoid bursa, AC joint, bicipital groove, supraspinatus, scapular angle, scapular medial or lateral border ). No cervical or thoracic spinous process tenderness, ROM: -Flexion [(~180°)] -Extension [(~45°] -Abduction [(~180°)] -External rotation [(~90°)] -Internal rotation [(~70°, or reach up the back: “hand behind back”)] -Strength: biceps power [intact bilaterally 5/5.] [Recognize the chief complaint. If it is cervical or neck pain, use the following:] -Inspection: Normal cervical posture, no deformity, no atrophy or asymmetry. -Palpation: Non-tender midline, mild paraspinal muscle tenderness [at the pain location], no lymphadenopathy. ROM: -Flexion [(~45–60°)] -Extension [(~45–60°)] -Lateral flexion [(~40°)] -Rotation [(~80°)] -Thoracic spine alignment (Kyphosis, scoliosis or normal) But mild discomfort at extremes. Neuro: -Power 5/5 -C5–T1, sensation intact, -brachial reflexes 2+ symmetric, Special tests: Spurling’s (positive or negative), Lhermitte’s (positive or negative), Hoffmann’s(positive or negative). [Recognize the chief complaint. If it is knee pain, use the following:] Inspection: Alignment (varus or valgus), muscle bulk (quadriceps, hamstrings), patellar position, swelling, effusion, scars, skin changes. Palpation: Joint line tenderness (medial and lateral), IT band tenderness, patellar tenderness (positive or negative), patellar mobility (positive or negative), effusion (positive or negative), (bulge sign, patellar tap), medial and lateral collateral ligament tenderness (positive or negative), popliteal fossa tenderness (positive or negative). Range of Motion (ROM): Flexion, extension — both active and passive. Special tests: McMurray’s test, Thessaly test, Lachman test, anterior drawer test, posterior drawer test, varus stress, valgus stress, patellar apprehension test. Neurological exam: Lower limb strength (quadriceps, hamstrings), reflexes (patellar, Achilles) (Normal ( 2+ symmetric), Hyporeflexia or hyperreflexia) , Sensation (normal or changed) (L5-S1 dermatomes).

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Procedure

Trigger Point Injection -Location: ( based on the location of the chief complaint, such as cervical paravertebral muscles) -Response: Immediate relief observed. -Details: Significant relief and discomfort improvement after TPI, today. No immediate complication after the procedure. -Volume: Total Volume: [Must be 10 mL for cervical / 15 mL thoracic / 20 mL lumbar] -Drug Used: Mix of 10:90 lidocaine 1%: saline 0.9% -Needle Gauge: 27G -Needle Load: Medium -Technique: Aseptic technique; needle advanced into taut band with multiple passes until local twitch response or tissue release obtained Complications: Minor blood spots managed with homeostasis measures

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Assessment

[Provide a clinical impression as " chief complaint locatoin Myofascial pain" based on history and examination. Include likely etiology, symptom triggers, and note absence or presence of concerning findings. For example: [Neck Myofascial pain]. Symptoms exacerbated by [factors]. No evidence of [negative findings] on exam

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Plan

[Outline the plan for continued management. Include recommendations for monitoring symptoms, lifestyle advice, medication or therapy continuation, follow-up scheduling, and instructions for the patient regarding symptom tracking and reporting new or worsening symptoms.]

Plan

[Outline the plan for continued management. Include recommendations for monitoring symptoms, lifestyle advice, medication or therapy continuation, follow-up scheduling, and instructions for the patient regarding symptom tracking and reporting new or worsening symptoms.]

Patient Consent

[Document that the patient has provided informed consent for any procedures or treatments discussed. Include mention of discussion of risks and benefits. -Post-Procedure Instructions: 1-Ice to site PRN for 24 hours 2-Avoid strenuous activity for 24 hours 3-Resume gentle stretching next day 4-Expect transient soreness for 24–48 hours 5-Seek care urgently for infection, progressive weakness, or new neurologic symptoms]