Thoracic segmental dysfunction

The patient is here for a followup visit with chronic mid back pain. Pain is intermittent and is getting gradually better and varies between 2-5 on the visual analog scale and as pain is getting better, she wants to gradually cut down on this pain medication. She denies any memory impairment, oversedation, nausea, itching, or high with medications. She has better quality of sleep at night. She denies any change in past medical history or surgical history.

DIAGNOSES:
Thoracic segmental dysfunction.
Myofascial pain syndrome.

RECOMMENDATIONS:
I will decrease OxyContin to 10 mg once a day #30 dispensed. No signs of abuse. We will see her back in 30 days period of time and then gradually cut down to OxyContin 5mg and hopefully we will stop it if the pain continues to get better.

Advertisements

Leave a Reply