The patient comes in today for a follow-up visit. She continues to have chronic neck and lower back pain with associated numbness and tingling radiating down both upper extremities into hands and fingers and down both lower extremities on the left greater than right. She also has pain focal on the left knee as well from motor vehicle accident. She has been doing acupuncture treatments, which is providing temporary relief of her symptoms. She had EMG studies recently and was recommended for lumbar epidural steroid injection. Pain level is 9/10 on visual analog scale without medications and 5-6/10 on visual analog scale with medication. She has been taking the Roxicodone four times a day and at times five times per day. This is keeping the pain at tolerable level. She denies any memory impairment, oversedation, constipation, nausea, itching, high or buzz on the medications. She is alert and functional with better quality of life since coming to the Center. She denies any change in past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems.

Lumbar disc herniation.
Lumbar radiculopathy.
Cervical radiculopathy.
Bilateral carpal tunnel syndrome.
Left knee pain.

I recommend bilateral transforaminal epidural steroid injection at L5-S1. We will get her scheduled for the injection as she has been approved by her insurance company. I also recommend an MRI of the left knee to further evaluate her knee pain. I will continue her Nucynta 150 mg one q.12h., #60 dispensed. We will decrease the Roxicodone 15 mg down to one every six hours as needed for breakthrough, #120 dispensed for the month. I will see the patient back in 30-day period of time. If she has any problems in the interim, she will contact the office.


Leave a Reply