The patient is a 36-year-old male with a greater than 10-year history of bilateral hand pain and approximate 6 year history of low back pain. The patient reports bilateral hand pain with the diagnosis of carpal tunnel syndrome. He denies any specific inciting event or trauma. He reports that he has had electrodiagnostic testing, which was given him the diagnosis in addition of his clinical diagnosis. The patient also has a long history of low back pain. He reports at least six-year history. He reports this occurred following two motor vehicle accidents and he also reports that he does a lot of physical labor with his job. He reports that he has had MRI scans performed, which did reveal herniated discs, but he does not have reports or films with him. He does report positive radiation of pain to the right greater than left lower extremity as well as numbness and tingling into the right greater than left lower extremity. He also reports weakness to the bilateral lower extremities. He has had interventional procedures done including a right L3-L4 foraminal nerve block, right L4-L5 foraminal nerve block, and a right L5-S1 foraminal nerve block. He reports these were done “a couple of years ago.” He also reports trigger point injections in the past, which provided some temporary relief.
1. Bilateral carpal tunnel syndrome.
2. Chronic lumbago.
3. Lumbar radiculopathy.
4. Myofascial pain secondary to all the above.
The patient was seen by me as well as Dr.x . Dr.x did write a two-week supply of OxyContin for the patient to continue with this medication as previous. He did discuss all risks and benefits. He did sign the patient medications management agreement. The patient will bring all of his recent medical records at his next visit with Dr.x to review. At that time, we will consider additional diagnostic tests if necessary. The patient will call with any questions or concerns prior to this.