0

MHNI Visit #5

Mother/Daughter day aka more Dr apts. We tried a new restaurant out today and are having lunch between apts at Noodles and company.

Really the only changes that occurred today were that Lyrica was increased to 150 mg a day and Imitrex 100 mg was added as an abortive medication.

I did receive the Doctor notes from my pain psychologist and it is always interesting to see what I talk about and what I am stressed about, etc.

Medical notes from Dr. Lake

Headaches: Mixed experience with headaches since RFA procedure with Dr. Shamas on 5/22/15.  She had some significant improvement within about a week of the RFA which would be unusual as a direct result of the RFA.  At that point she began doing more when the pain level was at a low range (1-2 on a 5 point scale), may have done too much, her headaches escalated, and she began to back off on the level of activity.  More recently in the past 2 1/2 weeks there has been mixed ups and downs with some severe headaches back up to the incapacitating level, but she understands this is still quite early to determine the efficacy of the RFA procedure – we would not respect significant results this early.

Botox: It was her understanding it would be scheduled today with Dr. Da Silva.  I am giving her chart to our charge nurse to confirm that the product is available and planned for today’s visit although that does clearly appear to be Dr. Da Silva’s intention in documentation of the chart (unfortunately Heather informed in a passing conversation with me at the end of the day that her insurance will not cover Botox at this time – I did not have an opportunity to explore that further).

Return to Work Issues: We faxed the FMLA forms that she had given us to her work Human Resources group on 5/22/15.  Heather informed me today that although we had extended her return to work date until 8/16/15, her work has given her another form different than the last one that they insist must be completed today.  I am arranging for her to talk with Margaret in our medical records group to review the form and determine what might be reasonable in terms of communicating with them and actually completing this.  To get this kind of form completed on the day she is seen here is not a reasonable expectation, but she will show it to Dr. Da Silva and get his overall view of it.  I do not believe she is in any position to sustain a successful return to her former job at this time and we will need to reassess in early August if it would be possible for her to return to work by 8/16/15.

Carpal tunnel syndrome: She has had some episodes of significant carpal tunnel symptoms in the past, and has carpal tunnel braces that she wears when symptoms flare.  Normally she does not wear it.  She had some issues with her right arm that she addressed by wearing the brace continuously for a period of time, and function and appearance improved significantly.  I encouraged her to consider wearing the brace routinely at night, to minimize any low-end RE:incipient irritations of the nerve.  This is particularly critical both in terms of her work as a microbiologist but also in terms of her alternative potential employment as a photographer since she holds the camera with her right hand that is difficult when the carpal tunnel is acting up.  She has however taken some pictures recently of her kids showing me the change from the first and last day of school and a recent haircut and is trying to be more active in general.

Functioning: She stated she is trying to do more walking and other activities when she feels better, trying to find the right balance between overextending herself as noted above when she had those 5 good days in a row shortly after the RFA.

Cognitive functioning: She continues to report some words switching such as telling her kids “load the refrigerator” when she meant loading the dishwasher.  Although she has had occasional examples of this occurring in the past, the frequency is now several times a day, and appears correlated with increasing her dose of Lyrica.  She states when she does at the beginning of the week it is more noticeable and appears to improve a bit as the week progresses.  She is currently at 125 mg twice a day and will be titrating to Dr. Da Silva’s recommended 150 mg twice a day.  She is not sure at this point how much Lyrica is helping her.  She did report some similar kids of issues at my last session with her before the RFA procedure.

Adherence with relaxation and biofeedback techniques: Excellent.  We did not have an opportunity to review some of that in session today but she gave me examples of using the techniques on an ongoing basis as well as helping herself relax as she goes through the physical therapy procedures with her neck which she feels is helping improve range of motion function as well.  She will see our physical therapist Andrea Sherman later today and request another physical therapy prescription.

0

MHNI Visit #3

My mom and I are on our way to down to MHNI for a full day of apts. Today’s visit will also determine if I will be able to continue on Short term disability and whether or not my job will any longer be held for me. So much in limbo right now. My last day of FMLA is May 25th and STD lasts until Aug 6th. I’m not even sure what to pray for at this point. But they will do another nerve block today which will hopefully give me a week of relief but when it wears off the migraines and headaches come back in full.

Today I met with Dr. Lake (pain Psychologist), Dr. Da Silva (Neurologist) and Andrea (physical therapist.  The main things that came from this were that they titrated Norflex daily down to stop the medication due to side effects.  I was still also increasing Lyrica (but side effects from Lyrica were also starting to take effect as the dose increases, but I am still willing to give it a try). Dr. Da Silva also recommended that I meet with the General Pain Division, Dr. Shamis to see if there might be more options for other nerve blocks to try.  Dr. Da Silva also did another nerve block in my temples and doubled the steroid.  I am very much looking forward to a few days of pain relief.

Starting to lose hope that the doctors will ever really figure out what is going on and how to help solve it.

image

Medical Notes from the visit to MHNI

Headaches: Some improvement continuing, but has also had some very severe headaches typically related to extensive talking with a friend that triggered a three day incapacitating headache, exertion in combination with a head-down position when she took a walk with her family and watched her kids picking up rocks and head down position when working at the computer.

A supraortbital aricular temporal block from Dr. Da Silva on 4/22/15 gave her a clear week of relief wtih a headache level dropping to a mild level for extended periods of time.  The severe headache triggered teh the walk and looking down occurred exactly one week after that block.  She will have a repeat block today by Dr. Da Silva, followed by a possible Radio-frequency Nerve Root Ablation.

She reports an increase in stress concerning her ability to return to work successfully, and other financial concerns that are unrelated to work including trying to sell a rental house that they are in the process of repairing after it had been vandalized by their tenants.  Her FMLA expires on May 25th.  Her employer (Neogen) has sent her a note explaining that they will not be legally required to maintain her job for her, but may be willing to do so when they receive appropriate information from us.  She logged in the appropriate form with Medical Records today and I put her name up for discussion with multidisciplinary treatment team for our next meeting on Tuesday, May 19.  I am also sending her a copy of this note which outlines her progress and behavioral treatment.

As she explained the ergonomics of the job to me,  it involves a great deal of laboratory work, making media, working with big dishes of media, and working over a safety hood that requires her to lean forward and extend her arms out in front of her which put some strain on her neck and back musculature.  We discussed trying to keep her self centered over her hips, but I also talked with our physical therapist about these issues and how that might be addressed in physical therapy.  She is scheduled to see our physical therapist, Andre, shortly after this apt today.

Also, she has continued to have some cognitive issues with word finding and word substitution.  Her job requires significant Cognitive demands.  In my judgement we are making progress but not in a position where she will effectively make a return to work before May 25th.  However, this is a treatment team decision.  She will see Dr. Da Silva, her primary neurologist with our group later this afternoon.

Anxiety and depression remain improved: however some return of depression after the last weekend with severe headache after she spent three hours talking with her friend.

She reports excellent adherence with relaxation techniques, and states they are quite helpful with the moderate or low-end severe headaches although it is very difficult to relax when the headache reaches an intense or incapacitating level.

I introduced her to biofeedback training. Bitemporal EMG was 2.25 mcV at baseline which is normal range.  However, when she would talk, it would rise and remain about 7 mcV, requiring some sustained attention to bring it back to a lower level.  With visual feedback she was able to drop this to 1.5 mcV and sustain it at that level, at times dropping a little below that, which is our target range.  I underscored the importance of continued attention to jaw relaxation, particularly while she is doing other activities, and returning to her baseline after talking with some sustained attention.  The temporalis may play a key role in some of the vice-like pain over the ears extending to the top of her head.  She also reports pain at times in the TMJ area, that may even extend into the mandible.

Right cervical trapezius EMG was elevated to 3.5 mcV range at baseline.  With instructions to sit with good back support and imagine that she was suspended from a cord with extension of her spinal column aligning her neck through the top of her head, she immediately dropped to below 1.5 mcV.  We discussed the importance of ergonomics and how she keeps her head from being in a down position, using a music stand to hold papers that she may need to work from, consideration of getting a monitor at eye level rather than hunching over to look at her laptop, not sitting on the couch when working on her computer at home, consideration of a wireless keyboard that she could hold on her lap while looking at the screen at eye level.  We also discussed the importance of returning to good posture positions and jaw relaxation as a baseline condition.

I will see her again at her next medical return visit.  She stated the session was quite helpful to her.

Dr. Lake