Encounter — Thomas Brown

Follow-up for complex regional pain syndrome type I, right upper extremity. Patient reports moderate improvement with current regimen. Pain NRS 5/10 (down from 8/10). Allodynia decreased — no longer present on dorsum of hand. Skin color and temperature differential normalizing. ROM improving with OT. Currently on gabapentin 600mg TID, amitriptyline 25mg HS, topical ketamine cream. Reviewed mirror therapy compliance. Continue current medications. OT 2x/week. Return in 6 weeks.