Admission Note for Back Pain

DATE:

CHIEF COMPLAINT: Back pain

HISTORY OF PRESENT ILLNESS:

Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Weakness-, Sensation changes-
Bowel/bladder dysfunction-
Nausea- , Vomiting- , SOB- , CP- , Sweating-
Recent injury-
Similar back pain before-

ER Tx given-
Cough- , CP- , Fever/chills- , Skin rash- , Leg Swelling-
Headache- , Vision problems- , Sore throat-
Abdominal pain- , Black/bloody stools- , Dysuria-

PAST MEDICAL HISTORY (positives are circled):
MI CAD HTN DM Low back pain DVT Cellulitis Gout
Prior back injury
Arthritis Kidney stones UTIs
Catheterization Echo
Stroke CA PUD PVD COPD Asthma Gallstones

EGD Colonoscopy

PAST SURGICAL HISTORY (positives are circled):
Back surgery
Knee surgery Cholecystectomy Hernia GSW Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH (positives are circled):
CAD<> 55 yo DM Stroke HTN CA

SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol- heavy occasional last drink
Smoker:
Illicit drugs - cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarakable part from the above symptoms

PHYSICAL EXAM:

VITALS:

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD
LUNGS: CTA (B)
HEART: Clear S1S2, RRR
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema
PERIPHERAL VASCULAR: palpable
NEURO:
AAO x 3
CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B)
DTR: ++DTR
SENSATION: non focal
CEREBELLAR: non focal

LABS:


UA:
CXR:
EKG:

ASSESSMENT:
-Low back pain due to
Lumbar radiculopathy
Arthritis
UTI

PLAN:
-CBCD, BMP in AM
-UA
-Tylenol 650 mg PO q 4-6 hr PRN pain/fever
-Home meds
-Heparin 5000 U SQ BID

Signature:


Created: 2/2005
Updated: 03/08/2007