Follow Up Report Sample:
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Ms Hewitt was last evaluated in our office on May 18th. She has a history of lumbar post laminectomy syndrome and lumbar disc herniation. The pain in the lower back is radiating down the side of the right leg. Pain intensity is rated as a 10/10 and it has been worse over the last few weeks. Her migraines have also become more intense. Her sleeping pattern has been disturbed, sleeping only about two hours in the evening. We are prescribing her MS Contin 60 mg three times a day and Xanax 1 mg two tablets at night. These medications are providing her with about 40% relief at this time.
On examination she is alert and oriented. Manual muscle testing in the upper and lower extremities are 5/5. Sensation was decreased at the right L5-S1 dermatome and the left S1 dermatome. She had 1+ edema in both feet and ankles. Reflexes were +1 at the knees and absent at the ankles. Range of motion was full for flexion and decrease for extension
IMPRESSION AND PLAN:
Patient has lumbar radiculitis, spondylosis, post laminectomy syndrome, and also a history of fibromyalgia and migraine headaches. I am not making any adjustment to her medications. Her medication will be filled through PMC pharmacy and we will see her back in the office in one month.