Section 20-2-VI - Conducting the Initial EvaluationA thorough history and physical examination are the well-established foundation for diagnostic and therapeutic procedures.
A.HistoryThe history should include:
1. general information: name, age, gender, etc.;2. work history, including current job status and requirements of current job3. current employment status;4. impact on activities of daily living; 5. past and present psychological problems;6. previous physical, emotional, or sexual abuse;8. pain history, including site of pain, visual analog scale, duration, onset, characteristics such as burning, shooting, stabbing, as well as aggravating or alleviating activities;9. current and previous medication use;10. history of substance abuse (i.e. alcohol, smoking, street drugs, opioids); B.Review of SystemsThe initial evaluation should include a standard multipoint review of systems, including symptoms of sleep apnea.
C.Physical Examination1. The clinician should conduct and document: a. a thorough physical examination, which includes a detailed musculoskeletal exam, including range of motion, mobility, provocative maneuvers, etc. andb. a detailed neurologic evaluation. 2. Evaluation of nonphysiologic findings is critical in assessing if someone is a candidate for use of opioids. These signs should be measured routinely during the patient's care. This includes documentation of nonorganic signs such as: a. superficial and nonanatomic tenderness; b. pain with simulated axial loading and rotation;c. sensory and motor findings which are inconsistent with nerve root patterns or known organic dysfunction;d. inconsistent straight leg raise findings;e. overreaction to physical examination maneuvers;f. variability during formal exam, including variable sensory or motor exam as well as inconsistent tenderness; andg. inconsistencies between formal exam and observed abilities with range of motion, gait, and strength.