Chief Complaint Postherpetic pain. History Patient is a 28-year-old right-handed white male who is a fair historian. He states that last July, he started having issues, which he ultimately blames on a shingles breakout. He states that he was doing some exercises with barbells and felt significant pain along the left T7 dermatome. He then developed significant pain there. He went to a local hospital. I think that time, it was Maine Medical Center. He asked for an MRI and was shown to have some straining of the musculature in the T7 intercostal area. He later developed herpes shingles rash in that area. He was treated with acyclovir, but by his report, was not put on carbamazepine at the same time. Since then, he has had lancinating …show more content…
The rest of the review of systems were reviewed and are negative. Social History He still smokes. He rarely drinks alcohol. Family History Cancer. Past Medical History Gastritis, postherpetic neuralgia. Allergies Penicillin, amoxicillin. Medications Omeprazole, Dramamine, Flonase, Sudafed. Examination Constitutional Weight 150 pounds. Height 5 ' 8". Respirations 12. Pulse 69. General He is in no obvious distress. Mental Status He is oriented x3, alert, cooperative. Good short-term, long-term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration. Cranial Nerves Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula are midline. Normal auditory acuity. Normal shoulder shrug. Motor Was 5/5 all four extremities with normal tone. Sensory Was slightly decreased in the left T7 distribution. Also, he had a positive Tinel 's, when I pounded with the reflex hammer in the T7 root exit area just lateral to the spinal cord. Cerebellar Revealed good finger-to-nose, heel-to-shin, and rapid alternating motion.