The patient is a 47-year-old morbidly obese female who was the patient of the Dr. . For reasons that are unclear to me Dr. can no longer prescribe for her medications. Therefore, she was referred to this office. She has been kept on regimen of opioids with oxycodone and morphine that according to her has been keeping her pain under control. Her fibromyalgia has been treated mostly with opioid. She denies the use of other medications such as Cymbalta. In the past, they tried Neurontin, but it did not agree with her. She also presents with complaint of low back pain due to herniated disc. She received multiple epidural steroid injections in the past, (five years ago) which provided relief of the pain. It is not clear to me why she is receiving anymore epidural injections. She describes her pain as constant, feeling of numbness, and stabbing pain that radiate from her lower back down into both lower extremities, the right being worse than the left. The pain radiates all the way down to the toes. It is aggravated with any kind of exertion such as lifting, prolonged standing, walking, and bending her lumbar spine.
Bilateral knee pain has been present also for many years. In the past, the knee shows accumulated fluid and they were drained by her prior doctors and she had steroid injected at that time of her drainage. The last time this was done was approximately five years ago. She had this done by Dr. . Her knee pain is more of a burning and stabbing pain in both knees, the right being worse than the left. It is aggravated with standing and ambulation. She has not had any surgical interventions in the knees other than meniscal repair and arthroscopies. Patient states that she has been trying to lose weight also.
Her fibromyalgia pain is mostly in the upper back and into both upper extremities. It is a burning and stabbing pain.
She rates her overall pain as a 7/10. Her pains are constant and nothing other than the current opioid regimen help relief the pain. They only provide temporary relief but do not take the pain completely away.

1. Morbid obesity.
2. Smoker.
3. Fibromyalgia.
4. Radicular lumbar pain.
5. Herniated lumbar disc.
6. Degenerative disc disease, lumbar.
7. Bilateral knee osteoarthritis.
8. Right knee popliteal with a Baker’s cyst.

1. Weight loss.
2. Smoking cessation.
3. I prescribed the patient Cymbalta 25 mg b.i.d. She is currently taking Effexor, which I recommended her to stop taking. She is to report to this office any side effects or problems with the medication as soon as they happened. I believe she will benefit from this medication for her fibromyalgia. Although I did question the diagnosis of fibromyalgia since I pressed the several trigger points and did not elicit a painful response.
4. I will repeat the lumbar MRI in order to reassess the condition of her lumbar spine and also to entertain the possibility of performing lumbar epidural steroid injections. I discussed with the patient the policy of this office regarding prescribing of opioids medication. She will obtain a letter from her prior pain physician stating the treatment plan and the fact they are no longer going to be prescribing her opioids.
5. Follow-up will be done in one week or after she obtains the letter from her doctor.


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