DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old man who presents for followup for chronic pain. Unfortunately, there appears to have been some confusion with his last change in medication. We had asked him to take two Lyrica twice daily, and he says that he went down to one twice daily, so we are unable to assess whether the Lyrica seems to be helping him.
He says that he wears his brace on and off. He continues to complain of a numb area on his left leg, which is very painful and sensitive to rubbing. He says when he is at home, he wears loose pants. He says his pain is almost always a 7-8, never better than 7. He sleeps on his side on the couch so that he cannot roll on his back. He also says he reinjured his right knee. He was sitting with his foot hooked over the rung of a chair at his wife’s house and felt his right knee popped a bit.
The patient has been unwilling to try alternative options since then because he is worried that he might do something more to his knee. He says that he would refuse to have any sort of surgery on his knee even if it were indicated. He does not want any other surgery following his multiple spine surgeries, which he says have not helped him.
He complains of intermittent right-sided back and side spasms on and off.
PAST MEDICAL HISTORY: He has a history of anxiety, neck pain, COPD, depression, hepatitis C, herniated disk status post multiple spinal surgeries, low back pain and right knee pain.
MEDICATIONS: Baclofen 40 mg 3 times daily, Combivent p.r.n., Cymbalta 30 mg twice daily, fluticasone nasal spray p.r.n., lorazepam 1 mg daily p.r.n., Lotemax ophthalmic solution, Lyrica 1 capsule twice daily, nabumetone 750 mg twice daily, omeprazole 20 mg daily, oxycodone 10 mg 3 times daily, OxyContin 100 mg twice daily, and trazodone 100 mg at bedtime.
ALLERGIES: NKDA.
FAMILY HISTORY: Diabetes and thyroid disorder.
SOCIAL HISTORY: The patient is a smoker. He is married. He walks with a cane. He has at least one daughter living with him at home. His daughter has had some TMJ issues.
REVIEW OF SYSTEMS: As noted in the HPI above. In addition, he complains of some neck pain with numbness and tingling that goes down his left arm intermittently. Otherwise, as above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/78, pulse 96, pain 7-8/10, weight 210 pounds and BMI 31.
GENERAL: The patient is well appearing. He had his hands resting on his cane, which was behind his back to stretch his shoulders out when we came into the clinic room. He says that this seemed to help with his numbness and tingling in his arm.
LUNGS: Show good air movement, no wheezing.
HEART: Regular.
BACK: No tenderness on the right side or ribs. Diffuse tenderness over his surgical scars in the low back and centrally no point tenderness.
LOWER EXTREMITIES: Strength 5/5 and equal bilaterally at the knee.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old man presenting for chronic pain. We did talk with him regarding his low back pain. As noted, there was confusion about how he should be taking the Lyrica. We clarified this with him today. We are going to call him in two weeks to see if the higher dose of Lyrica is helping, and if not, then we will increase the Cymbalta to try and come up with a right combination.
We did talk about the chronic pain in him and the likely mechanism. He is willing to go to the pain clinic and thinks he now can get transportation to go, so we are going to refer him there. Otherwise, he is going back to see Dr. John Doe and will talk with him about his ongoing pain.
He is potentially interested in having an injection in his neck, as he is having more numbness and tingling there. With regard to COPD, he continues to work on his smoking. He seems a little bit less stressed today, and we will hope that at his next visit, we will be able to address this again. He is up-to-date regarding screening. We will see him back in about six months, earlier if necessary.
