Right sacroiliitis

The patient presents today for a follow-up appointment. She complains of right-sided low back pain. Her pain level ranges from 2-5/10 in intensity on visual analog scale. Her symptoms are exacerbated with prolonged sitting. She has no new complaints since her last office visit. She denies any bowel or bladder dysfunction, radicular symptoms, numbness or tingling involving her lower extremities. She initially had pain radiating down her right leg when I first saw her in initial consultation, but that has improved. She is taking half of a Percocet 5/325 mg for pain. She has no change in her past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems.

DIAGNOSIS:
Right sacroiliitis.

RECOMMENDATIONS:
I am scheduling the patient for this Thursday for a right sacroiliac joint steroid injection under fluoroscopic guidance. The risks, benefits, and alternatives treatment options with the patient and she understands. I am waiting for the report of her MRI lumbar spine without contrast. I would like to see the patient in two weeks after her injection for a followup appointment.

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