Medical Case Summary
DOI: 4/1/2004. The patient is a 70 -year-old male operator who sustained a work-related injury to his right knee, shoulder and head when he fell off a bike at the refinery.
As per medical report dated 6/6/16, the patient continues to take one tablet of Xanax 0.5 mg at nighttime. He notes that he gets anxieties during the day and nighttime. He continues to be forgetful and he reports trouble understating some information. He uses continuous positive airway pressure (CPAP) unit regularly at night. He notes that he takes Ambien 5 mg late in the evening and this helps him fall asleep and maintain his sleep. He reports no adverse reactions from the medication. He gets head shots about one or twice a month on average. These are usually located over …show more content…
the temple area and are stabilized by gabapentin. He is also getting Celexa from his psychiatrist.
Based on progress report dated 09/12/16 by Dr. Nudleman, the patient reports that his symptoms have been more or less the same. He continues to have head pain at times. He notes that it is more on the left than the right side. It begins with a sharp pain and then lasts variably for 15 minute s to 2 hours. He has been taking gabapentin for this.
Relative to his sleep disorder, he uses a CPAP at nighttime.
He finds that the Ambien 5 mg at nighttime substantially helps him. He has had no problems with it. He has had no somnambulism. In addition to that in the evening, with anxieties, he takes Xanax 0.5 mg one tablet in the evening. He notes that this has been good for him.
He reports that he sees Dr. Katz relative to his right knee. He has had substantial improvement and is now walking without any aids. His right shoulder, likewise has improved. He continues to have problem with short term memory. He has trouble concentrating. He subsequently has frustration relative to chronic illness of his wife.
Clinically today, he had some difficulty hearing. Despite having the hearing aid, he still has some difficulty with hearing. At times, there was some word hesitation.
Patient was assessed to have chronic problems with sleep disorder.
He was given a prescription for Ambien 5 mg #90 one at nighttime and Xanax 0.5 mg one in the evening #90 for his posttraumatic anxiety and stress disorder. Relative to the patient's post traumatic head syndrome, this is chronic and stable Relative to his cranial neuralgias, these are stable and currently on gabapentin.
Patient has been previously certified with 45 Tablets of Xanax 0.5 mg and 30 Tablets of Ambien 5 mg on 6/20/16 (Review
265274).
As per medical report dated 6/6/16, the patient continues to take one tablet of Xanax 0.5 mg at nighttime. He notes that he gets anxieties during the day and nighttime. He continues to be forgetful and he reports trouble understating some information. He uses continuous positive airway pressure (CPAP) unit regularly at night. He notes that he takes Ambien 5 mg late in the evening and this helps him fall asleep and maintain his sleep. He reports no adverse reactions from the medication. He gets head shots about one or twice a month on average. These are usually located over …show more content…
the temple area and are stabilized by gabapentin. He is also getting Celexa from his psychiatrist.
Based on progress report dated 09/12/16 by Dr. Nudleman, the patient reports that his symptoms have been more or less the same. He continues to have head pain at times. He notes that it is more on the left than the right side. It begins with a sharp pain and then lasts variably for 15 minute s to 2 hours. He has been taking gabapentin for this.
Relative to his sleep disorder, he uses a CPAP at nighttime.
He finds that the Ambien 5 mg at nighttime substantially helps him. He has had no problems with it. He has had no somnambulism. In addition to that in the evening, with anxieties, he takes Xanax 0.5 mg one tablet in the evening. He notes that this has been good for him.
He reports that he sees Dr. Katz relative to his right knee. He has had substantial improvement and is now walking without any aids. His right shoulder, likewise has improved. He continues to have problem with short term memory. He has trouble concentrating. He subsequently has frustration relative to chronic illness of his wife.
Clinically today, he had some difficulty hearing. Despite having the hearing aid, he still has some difficulty with hearing. At times, there was some word hesitation.
Patient was assessed to have chronic problems with sleep disorder.
He was given a prescription for Ambien 5 mg #90 one at nighttime and Xanax 0.5 mg one in the evening #90 for his posttraumatic anxiety and stress disorder. Relative to the patient's post traumatic head syndrome, this is chronic and stable Relative to his cranial neuralgias, these are stable and currently on gabapentin.
Patient has been previously certified with 45 Tablets of Xanax 0.5 mg and 30 Tablets of Ambien 5 mg on 6/20/16 (Review
265274).