The patient comes in today for a follow-up visit. He continues to have chronic mid back pain. He is getting adequate relief with his pain medications. He denies any memory impairment, oversedation, constipation, nausea, itching, high, or buzz on the medications. Pain level is 5/10 on visual analog scale with the medications. He is getting better relief with the MS Contin compared to Norco although he still has at times severe pain. The Soma is helping with spasms and for breakthrough pain as well. Ambien is helping with sleep at night. He denies any bowel or bladder dysfunction. He still has not had his epidural injection yet. Today we are willing to do to the injection and awaiting the surgery center’s approval for his insurance. He denies any changes in his past medical history, past surgical history, family history, social history, or review of systems.
We will continue MS Contin 30 mg one q.12h., #60 dispensed; Soma 350 mg one b.i.d., #60 dispensed; and Ambien 2 mg one q.h.s. p.r.n., #30 dispensed with no refills. These are helping with pain, spasm, and insomnia.
We recommend the thoracic transforaminal epidural steroid injection. Random urine drug toxicology performed today. I will see the patient back in 30-day period of time.