Voltaren Gaze: A Case Study
DOI: 5/4/1997. Patient is a 54-year-old female area merchandiser who sustained a work-related injury to her lumbar area after lifting a box of dictionaries.
Based on the medical report dated 07/17/15, the patient has continued benefit with the use of Lidocaine patches for her neuropathic pain. She has previously failed gabapentin, Cymbalta, trazodone, and Lyrica. She is unable to tolerate oral medications due to past medical history of stomach surgery due to buildup of bile. She states she has continued benefit with the use of her Lidocaine patches and Voltaren gel, only for her chronic pain. Furthermore, she reports she has a spinal cord stimulator that is approximately 7 years old and has continued significant relief with its use for chronic pain. The patient previously discontinued her opioid pain medications. The patient is being seen every two to three months for follow-up. …show more content…
She requests prescription for Voltaren gel as she states 50% relief with use twice daily for her spinal cord stimulator battery pain as well as associated right lower back, iliac crest and right hip pain. Of note, patient fell on 03/08/16 and fractured her right wrist and had laceration on her face. Patient continues to stay active. She also continues to have neuropathic pain in the right lower extremity to foot (sharp shooting and numbness).
On examination of the lumbar spine, there is mild tenderness. Range of motion shows forward flexion of 50 degrees, and extension of 10 degrees, with more pain upon extension. Facet stress test is positive bilaterally. Right leg and knee extension strength is 4/5. Sensation is diminished to pinprick and touch over the right L5-S1 dermatome. Spinal cord stimulator scar is noted, with tenderness over the battery
Based on the medical report dated 07/17/15, the patient has continued benefit with the use of Lidocaine patches for her neuropathic pain. She has previously failed gabapentin, Cymbalta, trazodone, and Lyrica. She is unable to tolerate oral medications due to past medical history of stomach surgery due to buildup of bile. She states she has continued benefit with the use of her Lidocaine patches and Voltaren gel, only for her chronic pain. Furthermore, she reports she has a spinal cord stimulator that is approximately 7 years old and has continued significant relief with its use for chronic pain. The patient previously discontinued her opioid pain medications. The patient is being seen every two to three months for follow-up. …show more content…
She requests prescription for Voltaren gel as she states 50% relief with use twice daily for her spinal cord stimulator battery pain as well as associated right lower back, iliac crest and right hip pain. Of note, patient fell on 03/08/16 and fractured her right wrist and had laceration on her face. Patient continues to stay active. She also continues to have neuropathic pain in the right lower extremity to foot (sharp shooting and numbness).
On examination of the lumbar spine, there is mild tenderness. Range of motion shows forward flexion of 50 degrees, and extension of 10 degrees, with more pain upon extension. Facet stress test is positive bilaterally. Right leg and knee extension strength is 4/5. Sensation is diminished to pinprick and touch over the right L5-S1 dermatome. Spinal cord stimulator scar is noted, with tenderness over the battery