Flexeril Case Summary

DOI: 4/24/2014. Patient is a 33-year-old female surgical technologist who sustained a work-related injury to her upper back while holding a patient upright during a spinal epidural. As per OMNI, the patient was diagnosed with thoracic outlet syndrome with secondary pain, numbness and tingling.
Per the supplemental QME report on 6/12/16, the patient’s future medical care includes ongoing management for her upper extremity symptoms and continued access to pain management for her neuropathic and other symptoms. The examiner opines that the patient should have an opportunity to consult with a vascular surgeon and ought to be offered thoracic outlet syndrome surgery.
Per the medical report on 9/6/16, the patient continues to experience intermittent …show more content…
She rates her pain as 6/10 on visual analog scale. She takes MS Contin twice a day for long acting pain relief and Dilaudid for breakthrough pain. Both medications can reduce her pain by 75%. The Flexeril is very effective in managing her spasms which reduces her pain. The Horizant is beneficial for neuropathic pain. The Fetzima is more effective in alleviating neuropathic pain, reducing the numbness by 75%. With the use of her medications, she is able to perform light cooking, attend doctor’s appointments, take showers, and do her hair. She is also able to do her laundry and she states that Restoril helps her sleep through the night. The patient is noted to be a surgical candidate to treat her thoracic outlet syndrome. There is moderate cervical paraspinal muscle tenderness on the left. There is mildly limited left-sided cervical rotation. Moderate tenderness to palpation is noted on the left anterior shoulder and pectoralis muscles, which produces numbness and tingling in her hands. There is mild tenderness to palpation of the thoracic paraspinals. There is severe tenderness to trigger point over the right rhomboid muscle. The patient reports gastritis with nonsteroidal anti-inflammatory drugs. The patient is

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