This is a 69-year-old female with the above-stated problems who has been getting physical therapy from Jae for three or four prior sessions and states that she has improved significantly with her peripheral neuropathy and desires to continue with that. Additionally, she complains of bilateral hip pain, which appears to be originating from the sacroiliac joint, worse on the right than the left at this time. She complains that with walking just a few blocks, the pain gets so severe that she needs to sit down. Today, her pain level in relationship to her peripheral neuropathy, the primary reason she is being currently treated is 2/10 which is reduced from 6/10 on the last visit a month ago. The patient has had EMG and nerve conduction study that was dictated on her last visit and showed peripheral neuropathy, which she had.
357.2, Diabetic peripheral neuropathy
Probable sacroiliac joint arthritis.
The patient is currently taking Cymbalta 30 mg p.o. q.d. for some of her pain syndrome. She had been on a higher dose in the past 60 mg but because she is having side effects that was reduced to 30 and appears to be helping her. She is on no other pain medicines at this time. The patient should continue with physical therapy for another four weeks and then additionally get chiropractic treatment directed at her bilateral hips. The patient was also instructed to bring in the results of the radiologic reading of her MRI of her lumbosacral spine. She may be a candidate for sacroiliac joint injection keeping in mind that she has elevated blood glucose related to her diabetes and the dose of a steroid will be reduced if that injection gets done.