UTI Intake - Adult

Subjective:
Chief Complaint:
Oxycodone tapering and refill

History of Present Illness:
The patient is currently being treated with baclofen and oxycodone. She has been taking oxycodone at a dose of 15 to 20 milligrams every three hours, approximately eight times a day. The patient is requesting a refill for a couple of months, which raises concerns about the quantity and duration of oxycodone use. There is a plan to initiate a tapering dose of oxycodone to manage her pain more effectively and safely. The patient has been referred to a neurologist and has a follow-up appointment with physiatry from Regional Rehabilitation Center. She was unable to attend an appointment for Finasteride due to being admitted. The patient is scheduled for discharge tomorrow and will have follow-up appointments in a week or two in the clinic, as well as with the surgical team.

Past Medical History:
The patient has been referred to a neurologist and has a follow-up appointment with physiatry from Regional Rehabilitation Center. She was unable to attend an appointment for Finasteride due to being admitted.

Past Surgical History:
Not mentioned

Family History:
Not mentioned

Social History:
Not mentioned

The Review of Systems:
Not mentioned

Current Medications:
The patient is currently being treated with baclofen and oxycodone, taking oxycodone at a dose of 15 to 20 milligrams every three hours, approximately eight times a day.

Allergies:

• Not mentioned

Objective:
Vital Signs:
Not mentioned

Physical Examination:
General Appearance: Not mentioned
ENT Examination: Not mentioned
Respiratory Examination: Not mentioned
Neurological Examination: Not mentioned

Test Results:
Not mentioned

Assessment and Plan:
- Chronic Pain Management (338.4): The patient is currently on a regimen of oxycodone, taking 15 to 20 mg every three hours, approximately eight times a day. There is a concern about the high dosage and frequency of oxycodone use, and a plan to initiate a tapering dose to manage her pain more effectively and safely.
Plan:
• Initiate a tapering schedule for oxycodone to reduce dependency and manage pain safely.
• Continue current baclofen therapy as prescribed.
• Referral to neurology has been made; follow-up with neurology to assess pain management strategies.
• Follow-up appointment with physiatry from Regional Rehabilitation Center is scheduled to evaluate physical rehabilitation needs.
• Ensure the patient is aware of the potential side effects of oxycodone, including the risk of dependency and the importance of adhering to the tapering schedule.
• Schedule a follow-up appointment in three weeks to reassess pain management and adjust the tapering plan as necessary.

- Medication Refill Concern (477.9): The patient requested a refill for oxycodone for a couple of months, which raises concerns about the quantity and duration of use.
Plan:
• Refill oxycodone prescription with a limited supply to cover until the next follow-up appointment in three weeks.
• Educate the patient on the risks of long-term opioid use and the importance of adhering to the prescribed tapering schedule.

- Follow-up and Referrals (610.0): No referral for physiatry or pain management was initially noted, but a follow-up with physiatry from Regional Rehabilitation Center is confirmed.
Plan:
• Ensure all necessary referrals are in place for comprehensive pain management, including potential referrals to pain management specialists if needed.
• Confirm follow-up appointments with the surgical team and in the clinic within a week or two post-discharge.
• Schedule a follow-up appointment in three weeks to review progress and adjust the treatment plan as needed.

Differential Diagnosis:
Not mentioned

Problem:

1. The patient is experiencing issues related to the management of her analgesic medication, specifically the use of oxycodone (338.29).

Plan:

• Medications: Initiate a tapering dose of oxycodone to manage the patient's pain more effectively and safely.
• Patient Education: Discuss the importance of tapering the oxycodone to prevent opioid dependence and manage pain safely.
• Follow-up: Schedule a follow-up appointment within three weeks to reassess the pain management plan and adjust as necessary.