Muscle spasm

The patient is here for a follow-up appointment status post left C6-C7 transforaminal steroid injection. With this, he has improved 50% in his pain in the neck and arm with tingling and numbness. He has also has a history of low back surgery several years ago and has numbness down the low legs. Presently, he is stable with a combination of Percocet one table three times a day p.r.n. for pain. He also takes Ambien for sleep. He denies any bowel or bladder involvement. Initially, he had problem with his bowel or bladder function, but now it has almost recovered. He has some slight weakness in his lower extremities. Otherwise, there are no other changes in medical history or review of systems.

Cervical spinal stenosis.
Cervical radiculopathy.
Muscle spasm.
Lumbar postlaminectomy syndrome.

The patient will continue with Percocet 10/325 one tablet three times a day p.r.n. for pain along with Ambien 10 mg p.o. q.h.s. I will see the patient back in follow-up in a month.


Leave a Reply