Ricky Brown

 Pacific Pain 
 Institute 
 Visit Note - Follow-up Visit 
 Provider: 
 Supervising: Erin Wiggins, M.D. 
 Performing: David Humphrey, PA-C 
 Encounter Date: 02/2020/12
 Patient: Mejia, Florentino (PT00001958) 
 Gender: Male DOB: 08/1984/14 Age: 28 year 2 month 
 Race: Other 
 Address: 1646 Travion #t #1, Fairfield CA 94533 
 Injury Date: 01/2020/10 
 Employer: Chevys Fresh Mex 
 Case Insurance: Gallagher Bassett 14246 
 Complaint: 
 Mr. Florentino is a 28 year old male here today for a follow up visit. He sustained injury at work 
 on Dec. 6, 2011. He is having pain in back and right leg pain. His current pain level is a 8 on the 
 1-10 pain scale. His pain is constant and he describes it to be a aching, dull, sharp and shooting 
 pain. His pain radiates up his neck and down his right leg. He is also experiencing numbness, 
 pins/needles in right leg and weakness in right leg due to the pain. Any prolong sitting, walking 
 and bending worsens his pain. To relieve the pain he takes medication and uses ice packs. 
 Patient reports some nausea and dizziness to his medications. Patient states his current pain level 
 is without any medications. 
 Current Medication: 
 1 Cyclobenzaprine 7.5 Mg Tablet SIG: Take 1 tab at bedtime 
 2 Medrox SIG: Apply to affected area 2-3 everyday 
 3 Pantoprazole 20 Mg Tablet Dr SIG: Take 1 tab daily everyday 

 ROS: 
 Neurologic: (+) numbness, (+) tingling.(+) right lower extremity weakness. 
 Examination: 
 Patient: Ricky Brown DOB: 08/1984/14 Visit: 09/2019/07 Page: 46
 646
