CHIEF COMPLAINT
Low back pain
HISTORY OF PRESENT ILLNESS
Mrs. T (53y/o) returns to clinic with ongoing widespread pain, back, elbows, knees and ankles. The pain is 6-10/10 in intensity. She is averaging 6/10. She reports weakness. There is no sensory loss or bowel/bladder issues. She was previously under the care of what appears to be a pill mill with getting ultrasound guided trigger points in exchange for hydrocodone. She does not have any functional benefit from their care. She was seen initially by me a month ago with due diligence completed. There is no pathology at this point that requires opiates. MRI was age appropriate with mild to moderate degenerative changes without compressive pathology. Pain is worse with most any activity, better with rest and meds. Alleges she cannot work due to pain.
She reports her pain is better with hydrocodone but not with tramadol. It is widespread, aching and burning
MEDICATIONS
The medications were reviewed with the patient at today's visit and the EMR was updated to be consistent with the current regimen.
SOCIAL HISTORY
Positive tobacco. Social alcohol. She reports looking for work.
REVIEW OF SYSTEMS
Positive for shortness of breath and wheezing, temperature intolerance, suicidal thoughts, fatigue and decreased libido. No unplanned weight loss, fever, ringing in the ear, recent hearing loss or dizziness. No recent change in vision or double vision. No recent chest pain, shortness of breath, wheezing, cough or bloody sputum. No recent nausea, vomiting, diarrhea, bloody stools or change in bowel habits. No recent change in urinary habits and no reported blood in the urine. No reported rash, bruising or change in fingernails. No recent new onset seizure, memory loss or temperature intolerance. There is no report of IV drug abuse or suicidal ideation. Depression and anxiety were discussed with the patient in the context of their pain and nay new recommendations are made below. A standardized depression screen was completed by the patient and scanned into the EHR.
PHYSICAL EXAMINATION
T: 98 BP: 125/80 P: 78
GENERAL
White female pleasant and cooperative. In general, the patient is well developed, well nourished, and appears the stated age in no acute distress. BMI is noted in the EHR and discussed below.
NEUROMUSCULAR
The patient is alert and oriented times three. Cranial Nerve II-XII are intact. Speech, coordination and concentration are normal and appropriate. No gross deformity or atrophy noted. Motor testing is 5/5 in all extremities. Sensation intact to light touch. DTRs are symmetric. There is bogginess about the MCP joints both hands with tenderness. There is reduced range of motion in the low back. Gait is antalgic without assist device.
SKIN
Skin appears normal without edema, erythema, lymph nodes or rash noted.
IMPRESSION
1. Lumbar spondylosis with degenerative disc disease.
2. Possible connective tissue disease.
RECOMMENDATIONS
Opiates are not appropriate at this time. We will set her up with physical therapy if covered by Medicaid. I will continue tramadol and increase it to three times daily. Continue Lodine 400 mg twice daily. She was counseled on risks and benefits of long-term NSAID use. We will modify her gabapentin to 600 mg in the morning and 600 mg in the afternoon and 1200 mg at night.
I could offer interventional care if she had a worse area of pain that was consistent but only if she were going to be gainfully employed to make functional benefits.
Diet and exercise counseling appropriate for BMI and diagnoses as listed above was discussed with the patient, specific exercises were demonstrated, and a handout was provided.
