The patient comes in today for a follow-up visit. He has chronic mid back and thoracic spine pain from disc herniation. He had a thoracic epidural injection on 02/20/2012 where he had a relief and decrease in his pain from the injection. Four days ago, he was in a store and was startled and he jumped in the air and came down landing on his feet and since then he has had severe soreness in his thoracic spine and legs. He was just taking the MS , more he is taking it, getting more nausea and dysphoria he is finding with this medication. He is back to the point where he is not sleeping at night. He has not been taking the Ambien due to his primary result of pain as well as anxiety. He called the office yesterday and I called him in one day supply of hydrocodone, Soma, and Ambien. He is feeling much better today. He denies any memory impairment, oversedation, constipation, nausea, or itching on the medications. Pain level is a 4/10 on visual analog scale and this morning before coming to the clinic, his pain was down to 0. He denies any change in his past surgical history, family history, social history, or review of systems.
We will discontinue the MS and prescribe the Norco 10/325 one q.6h. p.r.n. pain, #120 dispensed. We will continue Soma 350 mg one b.i.d., #60 dispensed with no refills and Ambien 10 mg one q.h.s., #30 dispensed with no refills for sleep. He has no one to take him for repeat injection, so at follow-up we will schedule him for a second thoracic epidural injection. Urine drug toxicology results from 02/01/2012 were pending; we will review at follow-up. Also consider P-Stim.
We will verify his insurance for a lumbar orthosis. I think the lumbar thoracic and lumbar orthosis will help provide stabilization and decrease on the patient’s pain and spasm.