The patient comes in today for a follow-up visit. He continues to have lower back pain radiating down the lower extremities with numbness and tingling. He also has pain in the knee joints. I have ordered MRI of his knees at last visit and for his lower back pain we will schedule to have a medial branch block. He has predominantly axial lower back pain. He was in the hospital for a week due to episode of shortness of breath and dyspnea. He has also been having nausea and vomiting following meals. He is scheduled to see a gastroenterologist in two weeks. He is taking Zantac. He is also scheduled for his stress test. Pain level is 9/10 without medication and 5-6/10 with medication. He denies any memory impairment, oversedation, constipation, nausea, itching, high or buzz on the medications. He is alert and functional with better quality of life since coming to the pain center. He is resting fair at night. He denies any other changes in his past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems.
Lumbar facet syndrome.
We will re-schedule the patient for his medial branch blocks as scheduled previously on the left L4, L5, and S1. Risks, benefits, and alternative options were discussed with the patient. Also, recommend MRI of the both knees. I have given a prescription for this today. We will continue with Roxicodone 30 mg one every six hours as needed for pain, #120 dispensed.
We will also give him Compazine 10 mg one every six hours as needed for nausea and vomiting, #30 tablets until he came and see the gastroenterologist. We will see the patient back in 30-day period of time for renewal of his medications. We will like to try to decrease the medications after his procedure.