At today’s visit the patient is accompanied by his wife. He is awake, alert and oriented. The patient report upper back pain, severity 2/10, dull, chronic, he takes Tramadol 50 mg p.o every 6 hours prn. He states that sometimes the tramadol is ineffective but he refused to take any stronger pain medication. The wife reports that the patient has a poor appetite and had a weight loss of over 30 lb since last year. She states that he takes megace and his appetite has improved a little. He reports intermittent constipation which is managed with miralax. He denies chest pain and shortness of breath. No acute distress
