Pain in the right lower extremity

The patient is here for follow-up visit. The patient is a pleasant male who has chronic right leg pain and pain in the right foot and ankle after an accident in the 1980s. He is stable on chronic opioid pain medications and is gradually cutting down on it and trying to maintain a balance between quality of life and the amount of medicine that he takes. He also takes Xanax for sleep and anxiety. He denies any memory impairment, oversedation, constipation, nausea, high on the medications. The pain level is about 5/10 on visual analog pain scale. He wants to bring down and cut down on his Percocet from 6 times a day to 4 times a day and is also taking Xanax to help him in the sleep.

DIAGNOSES:
Right limb pain and muscle spasms.
Pain in the right lower extremity.

RECOMMENDATIONS:
He will continue with Opana ER 20 mg one every 8 hours, prescription for #90 tablet was given. We will cut down Percocet 10/325 one tablet q.6h. p.r.n., #120 tablets were dispensed. Xanax 1 mg one tablet q.h.s. p.r.n. for sleep and anxiety, #30 tablets dispensed. I will see him back in follow-up in 30 days.

Advertisements

Leave a Reply