Cervical spondylosis

The patient presents today for his one-month medication management follow-up visit. He has been very stable since his visit last month and was currently using OxyContin 30 mg b.i.d. and Roxicodone 30 mg q.6h. for pain. He is approximately 15 years status post orthotopic liver transplantation and has been stable on his current medication regimen. No new complaints since his last visit.

PHYSICAL EXAMINATION:
In general, very pleasant age-appearing gentleman who presents alone today, in no acute distress. Conjunctivae are not injected. Sclerae is anicteric. Extraocular muscles are intact. Buccal mucosa is moist. He has preserved range of motion of cervical spine in extension but 80 degrees of lateral movement to the left and approximately 65 degrees to the right. He has 4+/5 strength in the biceps and triceps. I am unable to elicit any radicular-type symptoms.

IMPRESSION:
1. 15 years status post orthotopic liver transplantation at UMDNJ.
2. Cephalgia.
3. Suspected cervicogenic head pain.
4. Cervical radiculopathy.
5. Rotator cuff syndrome.
6. Cervical spondylosis.

PLAN:
I did give him one-month of OxyContin 30 mg b.i.d. and Roxicodone 30 mg q.6h. in addition to Elavil q.h.s. We will see him back in one month’s time or sooner if needed.

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