Office Visit Report Sample:
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Reason for OV: Neck, shoulder and low back pain.
This is a 68-year-old female PMH, generalized OA, cervical lumbar DDD, DJD and fibromyalgia returns after 2 ½ month without reporting any incidents of problems with pain until the last 3 or 4 weeks. She has dull achy pain in her neck, across her shoulder into her low back. Both areas the pain feels similar in quality and also feels very similar in quality to the pain that she had September of this year when Dr. Griffin gave her suprascapular nerve blocks. This pain becomes burning with certain head and neck movements. She has recently been on the Lyrica in stead of p.r.n. 50 mg b.i.d. for about the last 3-4 weeks. She is not really sure if the Lyrica is helping. She has been trying heat which helps a little bit but she hurts all over and it is “really bad”. She denies any weakness, numbness, pins and needles but this pain does get worse with head, neck and shoulder movements. Medications are reviewed.
PE: Vital signs: BP 100/70. P 72. R 16. Wt: 164 lbs. Patient is WD/WN, overweight and in NAD. A&O x 3. Mood and affect is flattened. HEENT: Unremarkable. Heart: RRR. Lungs: CTA. Abdomen: Protuberant but benign. Patient is neurovascularly intact. Gait is normal. Musculoskeletal: She has no signs of inflammation. There is no erythema, ecchymosis or swelling. She definitely has the “touch me not” syndrome. Upper body is dominant. She has multiple trigger point tenderness in the upper extremities and low back. None in the lower extremities.
ASSESSMENT AND PLAN:
1. Bilateral shoulder and neck pain secondary to trapezial muscle spasming and cervical muscle spasming with fibromyalgia flare.
Procedure note: Bilateral suprascapular nerve blocks were performed using Kenalog 30 mg with 3 cc of 1% Xylocaine injected under sterile technique into the suprascapular notch. Patient tolerated the procedure well and reported significant improvement in pain prior to leaving. She will continue to use the Lyrica 50 mg b.i.d. She has a follow-up appointment scheduled with Dr. Griffin in approximately two weeks. We will keep that appointment for now. If she is not better she will see him. If she is better she will call and cancel
2. Low back pain secondary to DDD and degenerative sacroiliitis.
Procedure note: Bilateral SI joint injections were performed using Kenalog 30 mg with 2 cc of 1% Xylocaine injected using a sterile technique. Patient tolerated the procedure well.
3. Hypogonadism. Patient is postmenopausal. Does not have a family history for osteoporosis as near as I can tell she is a nonsmoker. Both by her admission and previous medical records she may want to consider a DEXA and check vitamin D level. Extended visit.