Thoracic segmental dysfunction

The patient comes in today for a follow-up visit. She continues to have chronic mid back pain. She is stable with current pain medication. Pain level ranges between 5-8/10 on a visual analog scale. She denies any memory impairment, oversedation, constipation, nausea, itching, high, or buzz with medication. She is alert and functional with better quality of life since coming to the Pain Center. She is resting fairly well at night. She is taking two Roxicodone in the morning with some relief and that is all she is taking at this point. She denies any change in her past medical history, past surgical history, medication history, allergy, family history, social history, or review of systems. She did go to the physical therapy previously without improvement. She has also done chiropractic for her back pain.

DIAGNOSES:
Thoracic segmental dysfunction.
Myofascial pain syndrome.

RECOMMENDATIONS:
I will continue with oxycodone 10 mg two tablets in the morning. She states that she has 45 tablets left over. So, I given her prescription for 30 more and I will see her back in around four-week period of time. If she has problems in the interim, she will contact the office.

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