The patient is a 50-year-old male that is disabled due to his dermatomyositis and Raynaud’s syndrome. He was diagnosed 13 years ago with this condition. He has been suffering from severe muscle pain and stiffness of movement due to the dermatomyositis and the calcium deposits intramuscular in his arms, low back, and lower extremities. He has undergone physical therapy and chiropractic manipulations which does not really control his pain. Currently, he is on a regimen of Wellbutrin and Percocet that does help him get around. He has been referred to this office for further evaluation, treatment, and recommendations. His pain is severe enough to interfere with his enjoyment of life and activities of daily living. Despite of this, he maintains an active life in terms of participating in activities with his family and exercising periodically. He described his pain as follows. Duration: Constant. Quality and intensity: 9/10. Radiation: Both shoulders and upper extremities, low back, buttock, and lower extremity. Aggravating factors: Mostly everything that requires strenuous physical activity. Alleviating factors: Current medication that even helps control the pain. Description of the pain: Numbness, aching, and burning sensation
2. Raynaud’s syndrome.
3. Muscular calcifications.
4. Chronic pain syndrome.
1. Continue the Butrans patch at 10 mcg an hour. A prescription for four patches was given to the patient.
2. Voltaren gel prescription was given to the patient to apply up to three times a day as needed. He was advised of the potential side effects, risks, complications of the use of nonsteroidal anti-inflammatories. He understands and is willing to proceed.
3. We started the patient in physical therapy program to increase his range of motion, and strength of his muscles. We will also apply a pulsation therapy to try to breakdown some of the calcification in the muscle. This was discussed with Dr.. He will start therapy in one month.
4. Follow up with me in one month.
5. Lidoderm patch, apply two patches to the affected area, 12 hours on 12 hours off. This is to numb the area before the pulsation therapy is done.
6. His primary physician will continue prescribing his Percocet. The patient understands this. If there is any concern from his primary physician regarding this medication, he will provide a letter stating that they will not prescribe that medication any more. Therefore, I will continue with prescribing those medications.