WOPC 2

Chief Complaint

Pain medicine progress note template

History of Present Illness

[Do not include information about imaging or other investigations in this section.]

Physical Examination

[body part] EXAMINATION: Appearance: [Patient appearance, example comfortable at rest] Active range of motion: -Flexion: [Left/right/bilateral] - [degree] -Abduction: [left/right/bilateral]- [degree] -Internal rotation: [Left/right/bilateral] - hand to [body part] area Impingement tests: -Hawkin: [positive/negative/bilateral] [Left/right] -Near: [positive/negative/bilateral] [Left/right] Rotator cuff tests: -Jobe: [Left/right/bilateral] - [pain level] -Resisted ER: [Left/right/bilateral] - [negative/positive] -Subscapularis lift off: [Left/right/bilateral]- [negative/positive] -Empty can test: [positive/negative/bilateral] [Left/right] Other special tests: -Speed: [Left/right/bilateral]- [negative/positive] -O'brien: [Left/right/bilateral]- [negative/positive] -Scarf: [Left/right/bilateral]- [negative/positive] -Scapular winging: [Exam result of the body part, example like on descent from abduction] -Apprehension: [Left/right] [positive/negative/bilateral] SI joint tests: -One finger test: [negative/positive] -Tenderness over the PSIS: [negative/positive] -Distraction: [negative/positive] -Compression: [negative/positive] -Thigh thrust: [negative/positive] -FABER: [negative/positive] -Gaenslen: [negative/positive] -Sacral thrust: [negative/positive] -Manual gaping of the SI joint: [negative/positive] -Innominate rotation: [left/right] [anterior/posterior] Neurologic examination: -Sensation: [normal in all dermatomes of the upper limbs] -Motor: [normal in all myotomes of the upper limbs] -Tone: [normal, no clonus] -Deep tendon reflexes: [normal in both biceps, triceps, and brachioradialis tendons] Point of care ultrasound examination: [list of findings in point form]

Test Results

Impression

[Impression in bullet point. Include the anatomical structures that are causing the pain/ myofascial pain due to fascial adhesion in the neck and shoulder/osteoarthrosis of the knee/ligament and fascial laxity of the neck/and more]

Procedure

Consent was obtained. Sterile technique was used with injections. Aspiration was negative for air and blood prior to all injections detailed below. [procedure: trigger point injections/nerve blocks/nerve hydrodissection/prolotherapy/intra-articular injection/fascia hydrodissection] was performed using a [needle gauge]G x [needle length] inch needle. [solution/medication volume] mL of [list of medications and their percentages] was used: [Side]: [body part targeted/injected]. Treatment was tolerated well without complications.

Plan

[Plan in bullet point] [Do not include the procedure performed]

Plan

[Plan in bullet point] [Do not include the procedure performed]