DATE OF SERVICE: MM/DD/YYYY
IDENTIFICATION: The patient is an (XX)-year-old woman with a lower extremity neuropathy.
HISTORY OF PRESENT ILLNESS: We are seeing this patient in scheduled followup after last meeting with her six months ago. The patient has been taking gabapentin 300 mg b.i.d. for her lower extremity discomfort, which she describes as a tingling pain. She was having intermittent sharp pains, which have seemingly died down with the use of gabapentin. The patient has occasional sharp pain in her big toe only, but this seems somewhat infrequent and brief. She did try Lidoderm patches after her last visit, but did not find these particularly helpful. One of the main problems she has been having since her last visit is sleep disturbance, in which she has trouble getting to sleep and multiple nighttime awakenings. The patient has occasionally been taking a sleeping pill and continues to use her CPAP machine. Her discomfort remains in the tops of her feet, and she describes a sensation as if her feet are wrapped in cellophane.
CURRENT MEDICATIONS: Gabapentin 300 mg b.i.d., lisinopril 5 mg daily, hydrochlorothiazide 25 mg daily, Lipitor 20 mg daily, aspirin 325 mg daily, multivitamin, vitamin D 400 units daily, TUMS, and Metamucil.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Detailed review of systems is significant for sleep disturbance and hearing loss and is otherwise negative in detail.
PHYSICAL EXAMINATION: On examination, the patient’s blood pressure is 120/70, pulse 86 beats per minute, and respirations 16 breaths per minute. Pain is 0/10. Generally, the patient appears well and in no acute distress. Her neurological examination reveals that she is awake, alert, and oriented with intact language, recent and remote memory. The patient’s extraocular movements are intact. Her visual fields are full. Her face moves symmetrically. On motor examination, she has full strength throughout upper and lower extremities proximally and distally. Sensory examination reveals intact and actually increased sensitivity to pinprick bilaterally in the lower extremities symmetrically without clear deficits and vibration or joint position sense.
LABORATORY DATA: The patient had a parathyroid hormone level checked in early September that was within normal limits. The patient had a vitamin B12 level that was 546 in April and a thyroid profile that was normal.
IMPRESSION AND PLAN: The patient is an (XX)-year-old woman with what appears to be a mild axonal sensory polyneuropathy that has responded reasonably well to gabapentin. This is an idiopathic polyneuropathy and does not appear to have been particularly progressive. To attempt to improve her pain control, as she has gotten partial relief from gabapentin, we have recommended small dose of amitriptyline at night, which may also have added benefit in terms of her sleep.
We recommended that she take amitriptyline 10 mg q.p.m., increase to 20 mg in one to two weeks, and discontinue for the time being the 300 mg of gabapentin at night. If the patient tolerates amitriptyline well, she may add back the 300 mg of gabapentin in the next few weeks. We also recommended that she return to see us in three months for a followup evaluation to discuss this intervention and potentially adjust the doses of her medications as needed.
