A review of his medical records indicates that the patients physical therapy has stopped and he has spent the last month in bed, not leaving his bed because his wife is unable to transfer him safely. He is in the process of getting physical therapy reestablished through the VA. His comorbidities of chronic seizures, DM and hypotension has remained stable since last visit.
At today’s visit he is accompanied by his wife. He is awake, alert and oriented. He reports chronic back and neck pain which radiates across his shoulder. He describes his pain as dull with a severity of 7/10. He states that his pain leave him confined to his bed mainly in on position. His mobility has also decreased due to non activity. He denies chest pain, anxiety, depression
At today’s visit he is accompanied by his wife. He is awake, alert and oriented. He reports chronic back and neck pain which radiates across his shoulder. He describes his pain as dull with a severity of 7/10. He states that his pain leave him confined to his bed mainly in on position. His mobility has also decreased due to non activity. He denies chest pain, anxiety, depression