Chronic non-healing wound of bilateral lower extremities

The patient comes in today for a follow-up visit. She continues to have bilateral lower extremity pain. She has chronic non-healing wounds related to allergic reaction to ink from a tattoo. She began having developing a wound on the right leg as well as left. She is undergoing treatment at the center including debridement operations. She is waiting approval to get skin graft on the left lower extremity. She has some increased breakthrough pain this past month with the wound treatment that she has been undergoing. Pain level is 2-4/10 on a visual analog scale with medications and 10/10 without medications. She denies any memory impairment, oversedation, constipation, nausea, itching, high or buzz on the medications. She is alert and functional with better quality of life since coming to the pain center. She is able to rest well at night and function better overall. She denies any change in past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems. She denies any new injuries or changes in characteristics or nature of her pain.

DIAGNOSES:
Bilateral limb pain.
Chronic non-healing wound of bilateral lower extremities.

RECOMMENDATIONS:
We recommend she continue followup with surgical team at wound care center. She also will be following with an allergist for further evaluation as well. We will continue Nucynta ER 150 mg one q.12h., #60 dispensed and we will also increase her Dilaudid 4 mg one tablet three or four times as needed for pain, #105 tablets dispensed for the month. We will see her back in 30-day period of time. If she has any problems in the interim, she will contact the office.

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