Sample

 Note:  
Chief  Complaint:  The  patient  presents  today  with  increasing  knee  pain  in  the  left  knee.  
 
HPI:  56  year  old  AAF  presents  to  the  clinic  with  complaints  of  left  knee  pain.  Patient  states  pain  has  
progressively  gotten  worse  over  the  course  of  the  last  year  and  now  over  the  counter  pain  medications  such  
as  ibuprofen  and  Tylenol  are  no  longer  relieving  the  pain.  Patient  states  today  the  pain  is  8/10  in  intensity  and  
is  sharp  and  constant  in  quality.  Patient  states  the  pain  does  not  radiate,  but  sometimes  her  knee  “locks”  and  
she  feels  as  if  she  is  going  to  fall.  Patient  states  standing  for  long  periods  of  time,  walking,  and  climbing  stairs  
aggravates  the  pain.  Patient  states  she  has  tried  to  take  up  to  8  Ibuprofen  per  day  but  it  does  not  alleviate  her  
pain  for  more  than  a  few  hours.  Patient  has  also  tried  to  elevate  her  leg,  ice,  and  use  an  over  the  counter  
brace  with  minimal  relief.  Patient  does  not  remember  any  trauma  to  her  left  knee  in  the  last  year  prior  to  pain  
beginning.  Patient  states  she  is  unable  to  do  her  daily  activities  secondary  to  the  pain  and  as  a  result  she  is  
gaining  weight  and  starting  to  lose  hope  that  she  will  be  able  to  do  the  things  she  enjoys.  She  was  advised  by  
her  PCP,  Dr.  Jones,  at  Jackson  Park  Hospital  that  her  pain  is  from  “getting  older”.    She  was  referred  by  her  PCP  
for  evaluation  of  her  worsening  knee  pain.  
 
PMH:  Significant  for  Hypertension  and  hypercholesterolemia.  
 
PSH:  Significant  for  cholecystectomy  at  age  9  
 
All:  Penicillin  (Anaphylaxis)  
 
Medications:  Patient  does  not  remember  current  medications,  advised  to  bring  list  or  empty  bottles  on  follow  
up  visit.    
 
Social:  Works  as  a  waitress,  denies  EtOH  use,  Smokes  ½  pack  per  day  x  25  years,  denies  illicit  drug  use.  
 
FH:  Maternal  Grandmother:  Diabetes  Mellitus  Type  1,  Father:  CHF,  Mother:  Diabetes  Mellitus  Type  1  
 
DIRE:  16  
ORA:  1  
 
Review  of  systems:  Contributory  
 
General:  Denies  fevers,  chills  or  night  sweats,  weight  gain/loss  
   
Cardio:  Denies  chest  pain,  palpitations  
   
Pulm:  Denies  cough  
Patient  has  shortness  of  breath  w/  dust  exposure  
   
GI:  Denies  nausea,  vomiting,  and  diarrhea.  Patient  admits  to  constipation,  and  difficulty  swallowing  
   
GU:  Denies  pain  on  urination,  frequency,  and  urgency,  burning.  
   
Neuro:  Denies  headaches,  changes  in  visions,  numbness,  weakness,  or  changes  in  sensation  
 
Musculoskeletal:  Denies  any  pain  in  other  joints,  arms  back  or  neck  
Physical  Exam:  
 
General:  56-­‐year-­‐old  AAF  in  some  pain/well/distressed/calm/etc,  but  not  acutely  distressed.  Sitting  in  
wheelchair.  Well-­‐nourished.  
 
Gait:  Antalgic  gait  (antalgic  gait  is  defined  as  a  gait  that  develops  as  a  way  to  avoid  pain  while  walking),  or  
normal  gait,  or  limping  etc.  
 
Spine:  Neck  and  spine  have  no  noted  deformities  or  signs  of  inflammation.  Spinous  processes  palpable,  
midline,  and  nontender  to  palpation  or  Spinous  processes  palpable,  tenderness  to  palpation  of  L4-­‐L5.  No  
paraspinal  tenderness  or  paraspinal  tenderness  around  L4-­‐L5.  Flexion,  extension,  and  side-­‐to-­‐side  rotation  of  
cervical  spine  WNL  (or  causes  pain  i.e.  pain  on  extension  of  cervical  spine).  Flexion  and  extension  of  lumbar  
spine  WNL  (or  causes  pain  i.e.  pain  on  flexion  of  lumbar  spine).    
 
Extremities:  For  all  comment  on  edema  (i.e.  2+  pitting  edema  in  left  lower  extremity)    
• For  patient  with  wrist,  hand,  &  finger  complaint:  
o No  visual  deformities,  inflammation,  or  tenderness  of  bony  prominences.  No  anatomical  
snuffbox  tenderness  (if  patient  fell  on  outstretched  hands  etc.)  Full  ROM  in  DIP,  PIP,  MCP,  &  
carpal  joints  &  with  supination  and  pronation  in  right/left  hand.    Phalen’s  &  Tinel’s  tests  were  
negative  (or  positive)  in  right/left  hand.    
• For  patient  with  Elbow  complaint:  
o No  bony  deformities,  inflammation,  or  tenderness  in  olecranon,  medial,  lateral  epicondyle  of  
right/left  elbow.    Full  ROM  upon  flexion  and  extension.  Strength  5/5.    
• For  patient  with  shoulder  complaint:  
o No  bony  deformities,  inflammation,  or  tenderness  in  rotator  cuff,  biceps  tendon,  or  
acromioclavicular  joint.  Full  ROM  in  right/left  shoulder  upon  adduction,  abduction,  internal  and  
external  rotation.  Strength  5/5.  
• For  patient  with  hip  complaint:  
o No  bony  deformities,  inflammation,  or  tenderness  in  hip  joint.    Normal  ROM  upon  flexion  &  
extension,  internal  &  external  rotation,  abduction,  &  adduction.  5/5  strength.  Straight  leg  test  
negative.    
• For  patient  with  knee  complaint:  
o No  bony  deformities,  inflammation,  or  tenderness  in  bony  prominences  or  soft  tissue.  Full  ROM  
to  extension/flexion,  internal  and  external  rotation.    Crepitus  present  on  extension.  Lachman’s  
test  positive/negative.  Varus/Valgus  stress  tests  WNL.  
• For  patient  with  ankle  or  toe  pain:  
o No  bony  deformities,  inflammation,  or  tenderness  in  bony  prominences  or  soft  tissue  of  foot  or  
ankle.  Full  ROM  to  dorsi/plantar  flexion,  inversion  &  eversion.  
 
Neuro:  AAOx3.  CN  2-­‐12  grossly  intact.  Patellar  (put  any  reflexes  tested  in  upper  and  lower  extremities)  
reflexes  2+  bilaterally  (or  can  be  asymmetric  and  not  always  2+).  Sensation  to  fine  touch  and  pinprick  intact  (in  
affected  limb  i.e.  foot,  hand,  etc).    
 
CV:  S1/S2  normal.  RRR.  No  MGR.  Pedal  pulses  palpable  bilaterally.    
 
Skin:  Warm,  grossly  intact.  (Put  any  scars,  discolorations,  etc.  here).  
 
 
Care  Plan:    
Patient  seen  for  chronic  knee  pain  in  left  knee.  Patient  advised  to  get  X-­‐ray  of  knees  bilaterally  to  assess  the  
knee.  Patient  advised  that  knee  pain  may  be  a  result  of  age-­‐related  degeneration,  however,  confirmation  is  
needed  from  imaging.  Patient  given  order  form  for  bilateral  knee  X-­‐rays.  Patient  counseled  on  smoking  
cessation  as  it  can  cause  increased  degeneration  and  adverse  health  effects  and  educated  on  the  various  
options  of  smoking  cessation  such  as  nicotine  patches.  Patient  states  she  would  like  to  attempt  to  quit  on  her  
own  before  her  next  follow  up  before  she  tries  any  other  means  of  cessation.  Patient  counseled  on  dosage  of  
ibuprofen  and  the  negative  impacts  associated  with  increased  dosage.  Patient  given  Meloxicam  and  Tramadol  
to  aid  in  pain  relief  and  counseled  on  proper  use  of  medication.  Patient  advised  that  weight  loss  may  help  
decrease  the  pain  and  swelling.  Patient  advised  to  follow  up  once  she  gets  imaging  completed  so  we  can  
discuss  and  pursue  treatment  options.  
 
*If  the  patient  is  having  any  kind  of  psychosocial  issues  (i.e.  anxiety  or  depression),  it  needs  to  be  addressed  
below  as  such:  
 
Patient  states  she  is  having  severe  depressive  symptoms  such  as  loss  of  interest  in  activities  she  used  to  enjoy,  
early  morning  awakenings,  and  feelings  of  hopelessness.  She  denies  suicidal  ideation.  Patient  was  referred  to  
Dr.  Karla  and  will  schedule  to  follow  up  in  the  next  two  weeks.  
 
*  In  the  event  you  do  an  injection,  this  is  what  it  should  look  like:  

Patient  MRI  from  3/30/17  confirmed  tendinosis  and  tendinitis  in  the  bicipital  grove  in  the  right  shoulder.  
Patient  given  Kenalog  inject  in  the  right  shoulder.  Range  of  motion  significantly  increased  post  injection.  
Patient  made  aware  of  the  limitations  of  prescriptions  from  multiple  providers.  Advised  to  go  to  PCP  for  refills.  
2  Vials  NDC  Number:  0003-­‐0293-­‐05  Lot  Number:  AAM8303  Exp:  09/18  for  both  vials.    

Patient  Prescription  Monitoring  System:  Reviewed  

Tox  Screen:  Not  on  file,  new  patient,  patient  gave  sample  07/18/17.  
 
F/U  after  x-­‐ray  of  knees.  Care  team  and  patient  continue  to  have  ongoing  discussions  and  education  regarding  
diagnosis  and  treatment  options.  Patient  acknowledges  understanding  the  diagnosis  and  agrees  with  the  plan.  
   
The  physician  and  practice  have  a  controlled  substance  policy  that  includes  risk  assessment  and  
tox  screening.    The  patient  was  screened  for  potential  opioid  misuse.    The  patient  has  agreed  to,  and  been  
counseled  regarding  the  limited  benefit  and  addictive  potential  of  opioids  and  other  pain  relieving  
medications.  In  every  instance,  the  goal  is  to  have  patients  off  pain  medication  by  12  weeks  after  completion  
of  surgical  procedure.  Unfortunately,  it's  not  uncommon  for  patients  to  require  long-­‐term  pain  control  for  
their  musculoskeletal  conditions.  Because  of  the  limited  number  of  pain  specialists  who  accept  
Medicaid/Medicare,  we  may  have  to  extend  the  duration  of  time  patients  receive  pain  medication  while  under  
our  care.  Every  attempt  will  be  made  to  refer  the  patient  back  to  their  primary  care  for  referral  to  a  pain  
specialist.    I  spent  45  minutes  with  the  patient  today.    
   
This  document  has  been  created  in  an  EHR.  While  every  precaution  has  been  taken  to  be  detailed,  additional  
clarification  may  be  necessary.  
 
Sally  H.  Bob  F.  s