- Joined
- May 30, 2005
- Messages
- 21,258
- Reaction score
- 12,376
We get a lot of crappy notes from PCPs who have no idea what is going on and what should be done. And then we sometimes (rarely) get remarkable notes.
I appreciate the heck out of a doctor who takes the time to T up a patient like this for me. Kudos to Dr. B (in house referral).
Cervical spondylosis (M47.812)
Current Plans
Started traMADoL 50 mg tablet, 1 Tablet every day at bedtime, #30, 01/15/2024, Ref. x1.
Continued methocarbamoL 500 mg tablet, 1 Tablet at bedtime as needed, #30, 01/15/2024, Ref. x2.
Continued Lyrica 50 mg capsule, 1 (one) Capsule two times daily, #60, 01/15/2024, Ref. x5.
Referred to Lobel, Steven MD (Physiatry).
Routine.
Cervicalgia (M54.2)
Multilevel degenerative disc disease (M53.9)
DDD (degenerative disc disease), cervical (M50.30)
Cervical stenosis of spine (M48.02)
Cervical stenosis of spinal canal (M48.02)
BMI 31.0-31.9,adult (Z68.31)
Current Plans
Nutritional counseling, diet (S9470)
Pt Education - Weight Loss Diets *: overweight
Tobacco non-user (Z78.9)
BMI Range: 30-39.9 (E66.3)
Current Plans
Pt Education - Patient education including healthy food choices, exercise, and other health tips were relayed to the patient. Will follow up with future visit.
Nutritional counseling, diet (S9470)
Pt Education - How to Access Health Information Online using Patient Portal and 3rd Party Apps (updated)
Follow up as needed
Note: Patient here for follow-up today for his neck pain he is able to sleep better with the Robaxin. Because of his CAD were going to try to avoid NSAIDs. He has a little bit of mild instability with flexion extension at C3-C4. MRI with diffuse multilevel degenerative disc disease and mild spinal canal stenosis he has some moderate right-sided neuroforaminal stenosis C6-C7 his degenerative disc disease is moderate to severe. He has no new upper extremity findings his strength is symmetric bilaterally. Neck extension seems to make his axial pain around his neck slightly worse. His hand grip strength is symmetric bilaterally possibly just slightly decreased. However his upper extremity strength is symmetric and intact including his lower extremity strength intact as well he has no bowel or bladder incontinence. I will increase his Lyrica to 50 twice a day. As he has a history of neuropathy symptoms as well he was already on this. He likely has degenerative disc disease of thoracic and lumbar spine as well. I will send him to our spine specialist here Dr. LOBEL for further evaluation and treatment. Patient expressed understanding agree with plan we have room to titrate up his Lyrica. Emergency department precautions(signs and symptoms that would require emergency room visit) explained and patient expressed understanding. Discussed in detail medication side effects, risks and benefits of medication and proper use of medication, also any related labs or imaging results and their associated follow up plan were discussed with patient and patient expressed understanding. notes were completed with dragon dictation- there may be some spelling and grammar errors or omissions.
I appreciate the heck out of a doctor who takes the time to T up a patient like this for me. Kudos to Dr. B (in house referral).
Cervical spondylosis (M47.812)
Current Plans
Started traMADoL 50 mg tablet, 1 Tablet every day at bedtime, #30, 01/15/2024, Ref. x1.
Continued methocarbamoL 500 mg tablet, 1 Tablet at bedtime as needed, #30, 01/15/2024, Ref. x2.
Continued Lyrica 50 mg capsule, 1 (one) Capsule two times daily, #60, 01/15/2024, Ref. x5.
Referred to Lobel, Steven MD (Physiatry).
Routine.
Cervicalgia (M54.2)
Multilevel degenerative disc disease (M53.9)
DDD (degenerative disc disease), cervical (M50.30)
Cervical stenosis of spine (M48.02)
Cervical stenosis of spinal canal (M48.02)
BMI 31.0-31.9,adult (Z68.31)
Current Plans
Nutritional counseling, diet (S9470)
Pt Education - Weight Loss Diets *: overweight
Tobacco non-user (Z78.9)
BMI Range: 30-39.9 (E66.3)
Current Plans
Pt Education - Patient education including healthy food choices, exercise, and other health tips were relayed to the patient. Will follow up with future visit.
Nutritional counseling, diet (S9470)
Pt Education - How to Access Health Information Online using Patient Portal and 3rd Party Apps (updated)
Follow up as needed
Note: Patient here for follow-up today for his neck pain he is able to sleep better with the Robaxin. Because of his CAD were going to try to avoid NSAIDs. He has a little bit of mild instability with flexion extension at C3-C4. MRI with diffuse multilevel degenerative disc disease and mild spinal canal stenosis he has some moderate right-sided neuroforaminal stenosis C6-C7 his degenerative disc disease is moderate to severe. He has no new upper extremity findings his strength is symmetric bilaterally. Neck extension seems to make his axial pain around his neck slightly worse. His hand grip strength is symmetric bilaterally possibly just slightly decreased. However his upper extremity strength is symmetric and intact including his lower extremity strength intact as well he has no bowel or bladder incontinence. I will increase his Lyrica to 50 twice a day. As he has a history of neuropathy symptoms as well he was already on this. He likely has degenerative disc disease of thoracic and lumbar spine as well. I will send him to our spine specialist here Dr. LOBEL for further evaluation and treatment. Patient expressed understanding agree with plan we have room to titrate up his Lyrica. Emergency department precautions(signs and symptoms that would require emergency room visit) explained and patient expressed understanding. Discussed in detail medication side effects, risks and benefits of medication and proper use of medication, also any related labs or imaging results and their associated follow up plan were discussed with patient and patient expressed understanding. notes were completed with dragon dictation- there may be some spelling and grammar errors or omissions.
