CC Follow up ER visit for back pain. S The patient is a 59-year-old female who tells me in early June she was moving a rolling coffee table at home. She states she felt a twinge in her back and had pain that radiated down into her left leg. She does tell me she had similar symptoms years ago when she was working at a different job. She was diagnosed at that time with a herniated disk and did have steroid injections and was out of work for six months. She tells me since then symptoms have come and gone, but this was the worst case of it she has had for quite some time. She was given both Percocet as well as Valium in the Exeter Hospital Emergency Room and does tell me she took these and completed them. She currently is just taking ibuprofen. Overall, her symptoms are improving. She does tell me that she has noticed some …show more content…
She does ask for more pain medication, but states Ultram worked well for her. She tells me she was given one of these in the emergency room. I did give her a prescription for Ultram 50 mg one to two tablets every four to six 6 hours p.r.n. #20 given with no refill. I did suggest we could try physical therapy, but she states things are improving and thus she does not want to do this. The patient does have a history of irritable bowel syndrome and does request a refill her of her dicyclomine. This was given. The patient was diagnosed with asthma in her 40s. She is a smoker. She does use albuterol very infrequently. She would like a refill of this and this was given to her. She does tell me she had pulmonary function tests in the past, but I do not see any results of these in her chart. May want to consider ordering baseline pulmonary function tests at her next appointment. Healthcare maintenance. The patient is scheduled for a physical in October. She will do her blood work prior to