Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation – the nature and location of their pain.
History of Present Illness:
Onset: When did the pain start?
Location: Where is the pain? Is it localized or radiating?
Character: How would you describe the pain (e.g., sharp, dull, throbbing, burning)?
Aggravating factors: What makes the pain worse? (e.g., movement, certain positions)
Alleviating factors: What makes the pain better? (e.g., rest, medication)
Severity: Rate the pain on a scale (e.g., numerical pain scale, visual analog scale).
Duration: How long has the pain lasted?
Associated symptoms: Are there any other symptoms associated with the pain (e.g., nausea, fever, weakness)?
Past medical history: Does the patient have any underlying medical conditions that could be contributing to the pain?
Medications: What medications is the patient currently taking? (including over-the-counter medications)
Allergies: Does the patient have any allergies, particularly to pain medications?
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate).
General examination: Assess for any signs of distress or discomfort related to the pain.
Focused examination of the painful area: Look for signs of inflammation, swelling, tenderness, or deformity.
Neurological examination (if indicated): May be necessary if there is concern for nerve involvement.
Assessment:
Summarize the findings from the history and physical examination.
Formulate a working diagnosis for the cause of the acute pain.
Consider potential differential diagnoses based on the location, character, and aggravating/alleviating factors of the pain.
Plan:
Pain Management:
Address the pain with medications appropriate for the severity and suspected cause (e.g., NSAIDs, opioids).
Consider non-pharmacological pain management techniques (e.g., heat/ice therapy, massage, relaxation techniques).
Diagnostic Testing:
Order any necessary diagnostic tests to identify the underlying cause of the pain (e.g., X-ray, CT scan, MRI).
Consultations:
Consider referral to a specialist depending on the suspected cause of the pain (e.g., orthopedics, neurology).
Progress Notes:
Document daily assessments including pain level, response to treatment, and any changes in the character or location of the pain.
Note any new symptoms or changes in vital signs.
Update the plan as needed based on the patient’s progress.
Discharge Instructions (for patients with improved pain):
Continue pain medication as prescribed, following the recommended dosage and duration.
Apply heat/ice therapy as instructed (if applicable).
Maintain good posture and body mechanics to prevent further injury (if relevant).
Follow up with a healthcare provider for re-evaluation in (#) days (adjust based on severity).
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of acute pain.