SUBJECTIVE: This is a (XX)-year-old Hispanic female with a past medical history of anxiety and depression, being cared for by a psychiatrist in the past; gastroesophageal reflux; status post motor vehicle accident with chronic low back pain, on disability. The patient denied any surgery in the past. She came for initial visit complaining of the same problem with back pain, but this is nonprogressive, and it is chronic.
PAST MEDICAL HISTORY: As mentioned above.
PAST SURGICAL HISTORY: The patient denied any history of surgery in the past.
ALLERGIES: PENICILLIN.
MEDICATIONS: Alprazolam 2 mg three times a day as needed; ibuprofen 800 mg three times a day, this was changed to ibuprofen over-the-counter to be taken with meals as needed; hydrocodone/APAP 7.5/500 mg one tablet b.i.d. p.r.n. for the last three to four months; Soma 350 mg one tablet at bedtime p.r.n. for the last eight years; Effexor 100 mg daily; Prevacid 30 mg daily before meals; and multivitamins.
SOCIAL HISTORY: The patient is a nonsmoker and social drinker.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: HEENT: Unremarkable. CNS: Occasional headache. Left arm paresthesias as well as pain occasionally. Denied any syncope or presyncopal episodes. CARDIOVASCULAR: Unremarkable. PULMONARY: Unremarkable. GI: With occasional nausea, but no vomiting. No change in bowel movements. No melena, no hematochezia, no anorexia, and no weight change. GU: Unremarkable. MUSCULOSKELETAL: Low back pain, chronic, as well as leg cramps intermittently. INTEGUMENTARY: Unremarkable.
PHYSICAL EXAMINATION:
GENERAL: Showed a fairly nourished, fully developed female, alert and oriented x3, not in acute distress, ambulatory.
VITAL SIGNS: Temperature of 98.2, blood pressure 178/108, pulse of 84, respirations of 20, weight of 92 pounds, height of 5 feet 2 inches. Oxygen saturation on room air is 99%.
HEENT: Normocephalic. Pupils are equally reactive to light and accommodation. Pink conjunctivae. Nonicteric. No nasal or pharyngeal congestions. No oral lesions. No lacerations or any bleeding.
NECK: Supple. There is no mass. No palpable cervical lymph nodes. No bruit. No JVD.
CHEST AND LUNGS: Symmetrical in expansion. Clear to auscultation bilaterally.
HEART: Presence of first and second heart sound. No murmur, no gallop noted.
ABDOMEN: Soft. Flat. Presence of bowel sounds. There is no bruit. No hepatojugular reflux. Nontender.
EXTREMITIES: There is no leg edema. No clubbing, no cyanosis, no IV track marks noted. There are no epitrochlear nodes, no clubbing, no petechiae, no hematoma, no palmar erythema or any maculopapular rash.
NEUROLOGIC: Intact.
ASSESSMENT AND PLAN:
1. Chronic low back pain secondary to motor vehicle accident. Plan is to refill her usual medications, but change it to p.r.n., especially the narcotic agent hydrocodone/APAP and the Soma, as well as the Xanax. The patient will be referred to Pain Management for further evaluation and also to reduce the dependancy on the narcotic agent as well as the muscle relaxant.
2. Increased blood pressure. This might be a transient increase since the patient has run out of all medications listed and can be having some withdrawal symptoms. The plan is to cut down on the salt intake. Recheck the blood pressure in about a week.
3. Anxiety/depression. Continue with the medication with alprazolam as listed in the medication list, with Effexor. The patient will be referred to a new psychiatrist.
4. Gastroesophageal reflux. Plan is to continue with Prevacid 30 mg daily before meals.
5. Health maintenance screening. The patient will be seeing a gynecologist. Would also give the patient a screening form for mammography.
6. The patient will be advised to follow up in about a month.
