Free EMR Stamps
Acute low back pain
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S/ Presenting with acute low back pain
started «spontaneously» «with •»
ongoing for • «days» «weeks»
most pain in •
«no »radiation« to the •»
worse with •
better with •
currently using • for pain
«no »previous episodes «: •»
«no »trauma
«no »leg weakness
«no »bladder/bowel dysfunction
«no »saddle anesthesia
«no »fevers/chills/diarrhea
«no »personal history cancer
«no »morning stiffness lasting >30 min
O/Appears well, NAD
temp •
spine - no SEADS, no bony tenderness
gait «normal»
power 5/5 in LE key muscles
reflexes 2+ in LE's
AROM lumbar spine «normal» «restricted in»
«abdo SNT ND, no pulsatile mass»
«DRE done with consent + chaperone. Normal rectal tone, no saddle anesthesia.»
A/ Nonspecific low back pain «Radicular pain» «Spinal stenosis»
Unlikely to be • or • based on history/exam
P/ Discussed no red flags, expected to improve over next 2-6 weeks on its own, imaging not indicated at this time
Discussed importance of continuing usual activities as tolerated, all movements safe
For pain relief, can try:
- heat/ice to back BID x15 min
- Aleve PRN; advised to use < 2 weeks, avoid using more than one NSAID
«Physiotherapy in 2 weeks PRN»
RTC if not improving after 6-8 weeks, sooner PRN
To ER if saddle anesthesia, leg weakness, bladder/bowel dysfunction
Unintentional Weight Loss
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S/ «Unintentional weight loss»
Lost • over «weeks»«months» «(>5% of body weight in 6-12 months)»
Associated symptoms: •
FIFE: •
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Any new medications? «no»
Any recreational substances? «no»
Are you satisfied with your eating patterns? «yes»
Do you ever eat in secret? «no»
Does your weight affect how you feel about yourself? «no»
Eating disorder screening «(-)»
Within the past year, were you worried whether you’d run out of food before you had money to buy more? «no»
Within the past year, has the food you bought not lasted and you didn’t have money to buy more? «no»
Food insecurity screening «(-)»
Over the last 2 weeks, have you had little interest or pleasure in doing things? «no»
Over the last 2 weeks, have you felt down, depressed or hopeless? «no»
Depression screening «(-)»
ROS:
General: «no» fevers/chills/night sweats, fatigue, new rashes
GI: «no» nausea/vomiting/diarrhea, blood in stool, dysphagia, abdo pain
Neuro: «no» focal neuro weakness/gait changes/anosmia/REM sleep changes
Cardioresp: «no» cough/SOB, orthopnea/PND/pedal edema/CP
Endocrine: «no» hot/cold intolerance, loss of body hair, polyphagia/polydipsia
O/ Appears well, NAD, no pallor or jaundice
No lymphadenopathy
S1 and S2 heard, no ehs/murmurs, no pedal edema
GAEB no adventitia
Abdo SNT ND
A/ Unexplained weight loss
«Approx 30% of cases from cancer, 25% NYD, 20% psych (depression common), 15% non-malignant GI)»
P/ Discussed step-wise approach to investigation; approximately 25% of cases will have no identified cause
«BW req provided: CBC, rBG, A1C, lytes, Ca2+, Cr, liver function tests, ferritin, B12, TSH, CRP, Hep C, HIV»
«Provided req for CXR»
Cancer screening: «up to date»«due for»
RTC if new symptoms, concerned, worsening