Orthopedic Evaluation MedicalTemplate

Orthopedic Evaluation Patient DOB MRN Encounter Date
Review of Systems Chief Complaint Referring Physician

Yes No Pain Numbness Tingling Weakness Instability Swelling Stiffness
Constitution
Fatigue or Malaise
History of Present Illness Medication list reviewed Allergy list reviewed
Fever or chills
Eyes Location Right Left Bilateral
Vision changes Neck Upper Back Mid Back Lower Back Shoulder Pelvis
New eye pain Arm Elbow Forearm Hand Wrist Finger
ENT/mouth Hip Knee Thigh Lower Leg Foot Ankle Toe
Nose bleed
Jaw pain Quality
Respiratory Intermittent Constant Burning Aching Dull Sharp Stabbing Throbbing Ill-defined
Dyspnea Severity
Cough Mild Mild - Moderate Moderate Moderate - Severe Severe
E
Wheeze
Cardiovascular Pain Scale (Scale of 1-10; Lowest =1; Highest = 10)
Chest pain Left side 1 2 3 4 5 6 7 8 9 10
Diaphoresis Right side 1 2 3 4 5 6 7 8 9 10
Ankle edema
Syncope Onset Uncertain Gradual Sudden, without known injury
After an injury or accident Yes No Date __________________________
Gastrointestinal
Nausea or vomiting
Weight changes
Bowel dysfunction
Genitourinary
Hematuria
Dysuria
Bladder dysfunction
Musculoskeletal
Myalgias
Arthralgias
Joint swelling

Duration
Context PL
Work-related
Modifying Factors
Increased by
Decreased by
Unaffected by
Day

Night

Yes No Date reported to employer
Uncertain Days Weeks Months Years
Improved Worsening No Change

Rest

Associated Signs or Symptoms See Review of Systems
Activity Medication Ice/Cold

__________________________
Heat

Walking Climbing stairs

M
Recent trauma Pain Medications used for this problem
Range of Motion Over The Counter Ibuprofen Acetaminophen Other
limitations Prescription Ibuprofen Acetaminophen COX II Inhibitor Narcotics Steroids Muscle relaxer
Skin/Breasts
Masses Prior Evaluations or Treatments for this problem
New skin lesions Emergency Department Other Physician Physical Therapy
Sensitivity to sun Imaging None X-Ray Ultrasound MRI Bone Scan CAT Scan Lab tests EMG
Neurologic
SA
Seizures
Muscle weakness
Numbness Past Medical, Family Social History
Paresthesias Arthritis Heart disease HIV/AIDS Thyroid disease
Sexual dysfunction Asthma Valvular disease Malignancy Other
Endocrinologic COPD Hypertension Neuromuscular disease
Hair loss Diabetes Hepatic disease Renal disease
Polydipsia
Tremors ADLs This patient is able to perform the following independently Eating Bathing Dressing Toileting Transfers
Neck pain Vaccines This patient is current on the following Seasonal Influenza H1N1 Influenza Pertussis Pneumococcal Varicella Tetanus
Heme/Lymph
Bleeding gums Surgeries
Unusual bruising Arthroscopy Hip Replacement Knee Replacement Other orthopedic surgery
Swollen lymph nodes CABG Carotid Endarterectomy Peripheral artery bypass Other surgery
Allergy/Immunology
Social History / Risk factors
Sinus problems No Yes Tobacco use ____ # Packs X ____ # Yrs
Recurrent infections No Yes Alcohol use ____ Drinks per day week
Psychologic No Yes Recreational drug use Inhalational Injectable Ingestible
Mood changes No Yes Drug dependence Narcotics Benzodiazepines
Agitation
Occupational History
Hallucinations
Family Medical History

Asthma CHF COPD Heart Disease Hepatic disease Neuromuscular disease Thyroid Disease Other
ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

Vitals Exam WNL = Exam findings are Within Normal Limits
Height in cm ______ Constitutional (Must include 3 vitals)
Body Habitus WNL Cachectic Obese
Weight lb kg ______ Grooming WNL Unkempt
Respiratory
Temperature ______ Effort WNL Intercostal retractions Accessory muscle use
Respiratory Rate ______ Percussion WNL Dull Flat Hyperresonant
Palpation WNL Tactile fremitus
Pulse Auscultation WNL Wheezes Rhonchi Rub
Rate ______ Cardiovascular
Rhythm Regular Irregular Observation Swelling Absent Present
Blood Pressure _____ / _____
Varicosities Absent Present
Sitting Standing Supine Palpation Peripheral pulses Palpable, strong and symmetric Absent Weak
Edema Absent Present edema
E
Extremities Within normal limits Cool Cyanotic Tender
Labs Lymphatics (2 areas must be examined)
Exam WNL Lymphadenopathy Areas examined Neck Axilla Groin Other
\____/ ____ / ____ / ____ / Musculoskeletal (4 areas must be examined)
/ \ \ \ \ Head and Neck
Inspection WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
Range of Motion WNL Limited
Radiology
X-Ray

CT scan

Pain
Contractures
Stability
Inspection
Range of Motion
Pain
Contractures
Stability
PL
Strength and tone
Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Absent Present
WNL Dislocation Subluxation Laxity
WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
Spine, Ribs and Pelvis
WNL Misaligned Asymmetric Crepitations Defects Tenderness Mass Effusion
WNL Limited
Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Absent Present
WNL Dislocation Subluxation Laxity
MRI Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
M
Right Upper Extremity
Ultrasound
Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Contractures Absent Present
Stability WNL Dislocation Subluxation Laxity
Strength and tone WNL Flaccid Cog wheel Spastic Atrophy Fasciculations
SA
Other
Left Upper Extremity
Additional Findings Pain Active ROM Passive ROM Patient showed no signs of pain with Active or Passive ROM
Right Lower Extremity
Left Lower Extremity
Exam continued on page 3

Skin (4 areas must be examined
Inspection and Palpation WNL Scar Rash Lesion Café-au-lait spots
Head and Neck Other _______________
Trunk Other _______________
Right Upper Extremity Other _______________
Left Upper Extremity Other _______________
Right Lower Extremity Other _______________
Left Lower Extremity Other _______________
Neurologic
Coordination WNL Abnormal
Finger to Nose _______________________________________________________
Heel to Shin _______________________________________________________
Rapid Alternating Movements _______________________________________________________
Fine Motor Skills _______________________________________________________
_______________________________________________________
E
Deep Tendon Reflexes
Mental Status
Orientation Oriented to Person, Time and Place Disoriented to Person Time Place
Mood and Affect WNL Depressed Anxious Agitated
Supervising Physician Notes Impression and Recommendations

I have examined this patient, reviewed
the history, labs and radiographs
relevant to this patient, have discussed
this patient with the Resident, NP or PA
and I agree with the assessment and
plan as outlined. Note the following
additional impressions and
recommendations.
PL
M
SA
Physician Signature Signature

cc Resident C-FNP PA-C

Orthopedic Evaluation MedicalTemplate

Transféré par

Informations du document

Copyright

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Orthopedic Evaluation MedicalTemplate

Transféré par

Droits d'auteur :

Orthopedic Evaluation Patient DOB MRN Encounter Date

Review of Systems Chief Complaint Referring Physician

Uncertain Days Weeks Months Years

Improved Worsening No Change

Family Medical History

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

Supervising Physician Notes Impression and Recommendations

Physician Signature Signature

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

Vous aimerez peut-être aussi

Orthopedic Evaluation MedicalTemplate

Transféré par

Informations du document

Copyright

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Orthopedic Evaluation MedicalTemplate

Transféré par

Droits d'auteur :

Orthopedic Evaluation Patient DOB MRN Encounter Date

Review of Systems Chief Complaint Referring Physician

 Uncertain  Days  Weeks  Months  Years

 Improved  Worsening  No Change

Family Medical History

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

Supervising Physician Notes Impression and Recommendations

Physician Signature Signature

ĵ MB and RR 2011 e-Medtools.com Health Care Provider Initials

Vous aimerez peut-être aussi

Uncertain Days Weeks Months Years

Improved Worsening No Change