- Joined
- Oct 2, 2007
- Messages
- 4,182
- Reaction score
- 36
New Pt today - 32 yo f, on Medicare, pain in the:
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.
Yeah, bascially pandynia.
Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.
Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)
Intolerence to Lyrica (sleepy) and Geodon (paranoid)
Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.
Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left
Pt reports none of the injections helped for more than a few days.
PT 3 times over the past 3 years "made me worse every time"
Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).
Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.
For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.
Doing the right thing just doesn't pay. This patient is why our system is going broke.
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.
Yeah, bascially pandynia.
Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.
Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)
Intolerence to Lyrica (sleepy) and Geodon (paranoid)
Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.
Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left
Pt reports none of the injections helped for more than a few days.
PT 3 times over the past 3 years "made me worse every time"
Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).
Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.
For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.
Doing the right thing just doesn't pay. This patient is why our system is going broke.