Beginning Pain Screening Examination ____________________________________ Attending Nurse General: Reveals a _____ year old [obese morbidly obese] M F who is _____ alert and oriented _____ confused as to: _____ day _____ place _____ depressed appearing _____ lethargic _____ anxious appearing _____ appears in acute pain Scars are noted: 1. 4. 2. 5. 3. 6. Cardiovascular: _____ Normal S1 S2 HR _________ B/P ___________________ Other: _______________________________________________________ Lungs: The rule of the artery is supreme. _____ Clear to auscultation bilaterally Other: ________________________________________________________ Musculoskeletal/Neurological: 1. Gait He/she walks with _____ a normal gait _____ an abnormal gait: ________________________________ abnormality _____ a walker _____ a cane _____ is unable/severely limited in walking 2. Posture He/She stands with a. Posterior View Head _____ Midline _____ Sidebent Left _____ Sidebent Right Shoulders _____ Equal _____ Low on Left _____ Low on Right Iliac crests _____ Equal _____ Low on Left _____ Low on Right Trochanters _____ Equal _____ Low on Left _____ Low on Right b. Lateral View Cervical lordosis _____ Increased Thoracic kyphosis _____ Increased w/ apex @ T _____ _____ Decreased Lumbar lordosis _____ Increased _____ WNR Thoracic paravertebral fullness _____ Decreased _____ Equal Lumbar paravertebral fullness 3. _____ Decreased _____ Equal _____ WNR _____ Decreased L R _____ Increased L R _____ Decreased L R _____ Increased L R _____ WNR Standing Trunk Motion Standing trunk motion reveals Flexion 0 - 90 LLR RLR 35 LLB RLB 35 Extension RESTRICTION: 0 - 30 PAIN: -1 = 25% restriction (mild) 1 slash mark = 25% pain (1 – 2.5/ VAS 10) -2 = 50% restriction (moderate) 2 slash marks = 50% pain (2.6 – 5) -3 = 75% restriction (severe) 3 slash marks = 75% pain (5.1 – 7.5) -4 = complete restriction (very severe) 4 slash marks = 100% pain (7.6 – 10) Stork test is _____ Neg Left & Right _____ Pos on _____ Right _____ Left 4. Walking Neuro/Muscle check The following lower extremity muscle groups were tested, searching for weakness: Iliopsoas , Quadriceps, Tibialis anterior, Extensor digitorum longus, Extensor hallucis longus, Gluteus medius, Peroneus longus and brevis, Gastrocnemius and soleus, and Gluteus maximus. Findings reveal _____ Able to walk on toes _____ Unable to walk on toes S1 _____ Unable to walk on heels w/ feet neutral L5 (Gastrocnemius and soleus) _____ Able to walk on heels w/ feet neutral (foot extensor – extensor digitorum longus & brevis) Manual Test: hold all, except great toe, down while pt. dorsiflexes) _____ Equal bilaterally Weak: _____ Left _____ Able to walk on heels w/ feet neutral _____ Right _____ Unable to walk on heels w/ feet neutral (foot extensor – extensor hallicus longus) Manual Test: oppose dorsiflexion of great toe _____ Equal bilaterally Weak: _____ Left _____ Able to walk on heels w/ feet inverted (tibialis anterior) _____ Right _____ Unable to walk on heels w/ feet inverted L4 or Manual Test: pt. dorsiflex & invert while practitioner forces into plantar flexion and eversion: _____ Equal bilaterally Weak: _____ Left _____ Right 5. Seated position testing Lower Neuro/Muscle check Iliopsoas _____ 5/5 Bilaterally _____/5 Left T12-L3 _____/5 Right Manual: Practitioner stabilizes pelvis & pt. raises thigh off table (knee to ceiling) Quadriceps _____ 5/5 Bilaterally _____/5 Left L2-3-4 _____/5 Right Manual: Practitioner one hand above knee on thigh & one hand on lower leg as pt. raises lower leg Peroneus longus & brevis _____ 5/5 Bilaterally _____/5 Left Manual: pt. plantar flexes and everts against resistance _____/5 Right S1 Knee Jerks are _____/4 bilaterally _____/4 Left _____/4 Right L2-3-4 Ankle Jerks are _____/4 bilaterally _____/4 Left _____/4 Right S1 Hoffmann’s _______ Upper motor neuron dysfunction/Myelopathy Babinski _______ Lower motor neuron dysfunction/Myelopathy Lower extremity sensation to pin wheel testing is _____ Intact and equal bilaterally _____ Decreased over _____ Left _____ Right L/S ______________ _____ Hyperalgesic over _____ Left _____ Right L/S ______________ Upper Neuro/Muscle check & ROM Neck ROM: Flexion _____ unrestricted _____ restricted Extension _____ unrestricted _____ restricted Rotation _____ unrestricted _____ restricted Lt _____ restricted Rt Sidebend _____ unrestricted _____ restricted Lt _____ restricted Rt The following upper extremity muscle groups were tested, searching for weakness: Deltoid, Biceps, Extensor carpi radialis longus & brevis, Extensor carpi ulnaris, Flexor carpi radialsis & Flexor carpi ulnaris, Triceps, and Finger extensors Deltoid _____ 5/5 Bilaterally _____ /5 Lt _____ /5 Rt C5 Manual: Pt. abducts arm w/ elbow flexed @ 90 degrees and practitioner resists Biceps _____ 5/5 Bilaterally _____ /5 Lt _____ /5 Rt C5 Manual: Pt. flexes arm at elbow while practitioner holds elbow and resists, pulling down at wrist Wrist Extensors _____ 5/5 Bilaterally _____ /5 Lt _____ /5 Rt C6 (Extensor carpi radialis longus & brevis (C6) & Extensor carpi ulnaris (C7) Manual: Pt. extends wrist & practitioner resists Triceps _____ 5/5 Bilaterally _____ /5 Lt _____ ./5 Rt Manual: Elbow stabilized by practitioner and pt. extends forearm while practitioner resists C7 Wrist Flexors _____ 5/5 Bilaterally _____ /5 Lt C7 _____ /5 Rt (Flexor carpi radialis and Flexor carpi ulnaris (C8) Manual: Pt. makes a fist and flexes closed fist. Practitioner tries to pull out of flexion. Finger Extensors _____ 5/5 Bilaterally _____ /5 Lt C7 _____ /5 Rt (Extensordigitorum communis, Extensor indicis proprius and Extensor digiti minimi) Manual: Stabilize wrist in neutral and pt. exednds metacarpophalangeal joints & flexes interphalangeal joints Biceps reflexes are _____ /4 Bilaterally _____ /4 Lt _____ /4 Rt C5 Brachioradialis reflexes are _____ /4 Bilaterally _____ /4 Lt _____ /4 Rt C6 Triceps reflexes are _____ /4 Bilaterally _____ /4 Lt _____ /4 Rt C7 Upper extremity sensation to pin wheel testing is _____ Intact and equal bilaterally 6. _____ Decreased over _____ Left _____ Right C ______________ _____ Hyperalgesic over _____ Left _____ Right C ______________ Supine position testing Straight leg raising is _____ Neg Lt & Rt _____ + at _______ degrees Left _____ + at _______ degrees Right Patricks is _____ Neg Lt & Rt _____ + Left _____ + Right Thoracic Cage Motion: Movement in the thoracic cage reveals - 7. a. Upper ribs: Inhalation _____ equal & unrestricted _____ restricted Lt _____ restricted Rt b. Middle ribs: Inhalation _____ equal & unrestricted _____ restricted Lt _____ restricted Rt c. Lower ribs Inhalation _____ equal & unrestricted _____ restricted Lt _____ restricted Rt Leg Length: _____ Equal _____ Left long/short _____ Right long/short Lateral position testing Gluteus medius _____ 5/5 Lt and Rt _____/5 Left _____/5 Right L5 _____/5 Right S1 Manual: Pt. on side and abducts leg while practitioner resists 8. Prone position testing Gluteus maximus _____ 5/5 Lt and Rt _____/5 Left Manual: Pt. prone and bends knee; then extends (lifts) leg; practitioner resists and palpates muscle 9. Seated position testing again Seated trunk motion reveals: Sidebending _____ Unrestricted _____ Restricted Lt _____ Restricted Rt Rotation _____ Unrestricted _____ Restricted Lt _____ Restricted Rt Flexion _____ Unrestricted _____ Restricted Lt _____ Restricted Rt Paraspinal Hypertonicity _____ None _____ Increased Lt Lumbar _____ Increased Rt Lumbar _____ Increased Lt Thoracic _____ Increased Rt Lumbar _____ Increased Lt Cervical _____ Increased Rt Cervical Muscle groups: 1. 2. 3. Tender/Trigger Points _____ None _____ Positive: Location __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ IMPRESSION: I. EMORY PAIN ESTIMATE MODEL PATIENT CLASSIFICATION II. PAIN TYPE III. KEY LESION PAIN GENERATORS A. PRIMARY B. SECONDARY IV. MEDICAL PAIN IMPRESSION V. PAIN ASSOCIATED COMORBID FACTORS: A. B. C. VI. GENERAL HEALTH KEY LESION/S SUSPECTED/IDENTIFIED: A. B. ETC.
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