Left sacroiliitis

The patient is here for a follow-up of her chronic low back pain, mid back pain, and pain over the left sacroiliac joint. X-rays of the thoracic spine showed multiple degenerative levels. X-ray of L-spine did not show any evidence of any fracture. The pain continues to be significant at about 7-8/10 on the VAS. She has been going to chiropractic therapy with some relief. She has recently had an MRI of L-spine and I do not have the result of that. Pain is aggravated with walking and standing. Otherwise, there are no other changes in the past medical history and social history since the last visit.

DIAGNOSES:
Left sacroiliitis.
Lumbosacral radiculopathy.
Mid back pain.

RECOMMENDATIONS:
The patient is still in pain one month after the chiropractic manipulative therapy. I will schedule the patient for a left sacroiliac joint injection to help with her sacroiliac joint pain. I will also review the MRI of the L-spine and depending on the result of that, the patient may also need an epidural injection to help with the radicular component of the pain. In the interim, she will continue with Ultram on an as needed basis.

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