Diabetes mellitus type 2

The patient is a 90-year-old male who had an episode of shingles approximately two years ago. The lesions healed although he was left with a pain in the distribution of the V1 trigeminal nerve on the left side. He has been on Neurontin which has helped to control the pain. He has described his pain as follows. Triggering event: Shingles. Duration: Intermittent, comes and goes without anything specific to triggering. Quality and intensity: 5/10. Radiation distribution: Left V1 trigeminal nerve. Aggravating factors: Unclear. Alleviating factor: It goes away on its own. Associated factor: Numbness sensation along with tingling.

He also complains of a pain in the stocking and glove distribution bilaterally. It also started several years ago and has been worsening over time. He does have a diagnosis of diabetes. The gabapentin has also helped with this problem, but does not take it away. He described this pain as follows: Triggering event: Diabetic neuropathy. Duration: Constant. Intensity: 5-6/10. Radiation distribution: Bilateral stocking and glove distribution. Aggravating factors: Standing, walking, sometimes using his hands. Alleviating factors: None. Description of the pain: Numbness and burning sensation.

DIAGNOSES:
1. Postherpetic neuralgia on the left V1 distribution of the trigeminal nerve.
2. Stocking and glove distribution of peripheral neuropathy.
3. Diabetes mellitus type 2.

RECOMMENDATIONS:
1. We will do EMG of upper and lower extremities in order to document the presence of the peripheral neuropathy and to determine treatment. Continue the Neurontin at 300 mg one tablet p.o. three times a day.
2. I discussed with the patient in detail the neuropathy protocol. We spoke over the risk, benefit, alternatives and technical aspects of the procedure. He understands and agrees to proceed as soon as we have the EMG done to document the neuropathy.
3. I discussed with the patient that treatment options of the postherpetic neuralgia in the face are very limited. I will use Neurontin given the nature of the problem. Today, he is not having any pain in the face. We would treat this problem in an conservative way and continue the use of Neurontin.
4. A prescription for Neurontin 300 mg one tablet p.o. t.i.d. at night with 90 tablets that was called into the pharmacy for the patient.
5. Followup will be in three weeks to evaluate the patient and if he has any pain in the face at that time, we will plan on performing a V1 branch nerve block on the left side.

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