Lumbar spondylolisthesis

The patient is a 61-year-old female who was last seen in this office on August 15, 2012. She returned to the office a week after her initial evaluation with complaint that Nucynta is not helping control her pain. A Medrol Dosepak was prescribed to her, but did not provide her any relief of the pain. She had blood work last weekend. She has not done any of the x-rays or MRI that were ordered for her because of the need for pre-certification. She continues experiencing diffuse pain in her upper body, both shoulders, low back, and the left hip. I discussed with her the potential diagnosis that may include a rheumatologic condition for which she had blood work ordered already. We will wait until the results of blood work to decide the rest of the treatment plan. She may be referred to Rheumatology for further evaluation. I added to the blood work, Lyme titer since we have not added this for Lyme. The symptoms that she is experiencing could be also related to Lyme’s disease. She was on Savella in the past, but according to her she was started on the highest dose and then they titrated the medication down. Medication should be started on the lowest possible dose and titrate up. I discussed with her the use of Savella again, but we decided to use Lyrica at this time. I discussed with her the risk, benefit, and alternatives of this medication. The risks include but are not limited to an increased appetite, edema, somnolence and often. The patient will also read about the medication risk.

ASSESSMENT:
1. Chronic low back pain.
2. Lumbago.
3. Lumbar spondylolisthesis.
4. Lumbar radicular pain.
5. Left hip enthesopathy.
6. Cervicalgia.
7. Myofascial pain, possible fibromyalgia.
8. Chronic fatigue symptom.

RECOMMENDATIONS:
1. Lyme titers were added to the blood work.
2. We started the patient on Lyrica 50 mg one tablet three times a day. The medication will be titrated up and she will start taking one tablet p.o. q.d. for three days then increased to one tablet p.o. b.i.d. for three days and then increase one tablet p.o. t.i.d.
3. I advised the patient since she already filled up the prescription for Nucynta to take 1-1/2 tablet up to twice a day. She may increase it to 1-1/2 tablet of her 75 mg tablet up to three times a day.
4. Once blood work results are obtained we will decide no further treatment versus referring her to rheumatologist.
5. Waiting for performance of bilateral hip x-rays as well as cervical and lumbar MRI to be done.
6. Follow up in two weeks for further determination of the rest of the rest of the treatment plan.

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