This is a one-month follow-up visit for the patient who is here to discus treatment options for his chronic pain syndrome that is in multiple joints including his cervical spine, his lower back, his shoulders, arms, hands and feet of long duration and for prescription refill. The patient is a 63-year-old white male with long-standing rheumatoid arthritis involving multiple joints of his body. He also has some numbness and tingling in his arms and legs. Although he has had an EMG performed, we do not have the results for that. We have to discuss that with him on the next visit to include in his chart. He currently takes OxyContin 10 mg one p.o. twice a day and Norco 10/325 one pill four times a day and he comes in for monthly refill. He is compliant with his medications although it does not help his pain too much. Pain level is 8/10 which it normally is and was on the last office visit as well. He denies any bladder or bowel dysfunction. He denies cognitive dysfunction.
His medications include simvastatin 40 mg one pill q.d., amlodipine 2.5 mg one p.o. q.d., and Enbrel injections once a week. In addition, he takes OxyContin 10 mg b.i.d. and hydrocodone 10 mg, and Tylenol 325 mg one pill four times a day. He also takes pantoprazole 40 mg one tablet b.i.d. and iron 150 mg capsule every 12 hours. He has Carafate as well 1 g in 10 mL solution two tablespoon three times a day before meals.
714.9 Rheumatoid arthritis.
722.81 Cervical failed neck syndrome.
ASSESSMENT AND PLAN:
The patient has multiple joint pain related to rheumatoid arthritis. In addition, he has a psoriatic arthritis and he sees a rheumatologist regularly. In the past, the patient has been on nonsteroidal anti-inflammatory medications but had issue with severe gastric irritation and bleeding and has since been removed from those medications. Currently, since seeing Dr. he has been taking OxyContin and hydrocodone religiously with minimal results but his life is tolerable. On his last visit, he discussed with Dr. the possibility of trigger point injections with ozone in his neck or shoulder and today we discussed topical ointments that could be used that do not have much gastric absorption in addition to acupuncture. The plan is to come back in four weeks and see Dr. for trigger point injection with ozone for his left shoulder. A refill of his prescription of OxyContin and hydrocodone were given today. He will consider the topical ointments and he will consider acupuncture treatments. There is no invasive injection treatment recommended for him at this time.