CHIEF COMPLAINT
Mr. Morrison is coming in today to follow up for his chronic back pain.
SUBJECTIVE
This started a few years back. Following some snowmobile incidents. He had used heroin and gabapentin to treat the pain in the past. Today he comes in says he still has pain. He has been taking his amitriptyline not using the Mobic too much as it upset his stomach and he said it did not help very much and just looking for relief of his back pain. Overall, he says he is able to get through the day and do what he needs to do, it is worse in the morning when he gets up and says it takes him a little bit of time to get going and then it improves. States he has been doing light exercise, describes mainly various isolated weight on the machines available at the gym here.
OBJECTIVE
Blood pressure 131/83, temperature 97.2, pulse 88, respirations 16. Medications he currently has the Mobic and amitriptyline 50. Head, eyes, ears, nose, throat, normal. Lung sounds normal. S1, S2 normal. No murmur. No rub. Regarding the back, he is able to do forward flexion to about 80 degrees almost to 90 about 6 inches short of touching his toes. He can then extend his back towards the posterior about 20 degrees and says that gets a little pain on the legs. Bended leg with rotation does not elicit any back pain on the …show more content…
Reviewed the red flag symptoms of amitriptyline, told him to report those. We will go from 50-100. We will DC the Mobic since he is not using it and he does not have any interest in it. He did not like the stomach pains. We will add a capsaicin cream and see if that helps him out particularly in the mornings he can try that and see if that helps to get him going. We will have him back in two months see if we are making any progress, we still have some room to go. He was cautioned not to stop the amitriptyline without running it by us for fear of withdrawal
Mr. Morrison is coming in today to follow up for his chronic back pain.
SUBJECTIVE
This started a few years back. Following some snowmobile incidents. He had used heroin and gabapentin to treat the pain in the past. Today he comes in says he still has pain. He has been taking his amitriptyline not using the Mobic too much as it upset his stomach and he said it did not help very much and just looking for relief of his back pain. Overall, he says he is able to get through the day and do what he needs to do, it is worse in the morning when he gets up and says it takes him a little bit of time to get going and then it improves. States he has been doing light exercise, describes mainly various isolated weight on the machines available at the gym here.
OBJECTIVE
Blood pressure 131/83, temperature 97.2, pulse 88, respirations 16. Medications he currently has the Mobic and amitriptyline 50. Head, eyes, ears, nose, throat, normal. Lung sounds normal. S1, S2 normal. No murmur. No rub. Regarding the back, he is able to do forward flexion to about 80 degrees almost to 90 about 6 inches short of touching his toes. He can then extend his back towards the posterior about 20 degrees and says that gets a little pain on the legs. Bended leg with rotation does not elicit any back pain on the …show more content…
Reviewed the red flag symptoms of amitriptyline, told him to report those. We will go from 50-100. We will DC the Mobic since he is not using it and he does not have any interest in it. He did not like the stomach pains. We will add a capsaicin cream and see if that helps him out particularly in the mornings he can try that and see if that helps to get him going. We will have him back in two months see if we are making any progress, we still have some room to go. He was cautioned not to stop the amitriptyline without running it by us for fear of withdrawal