Lumbar radiculopathy

The patient is here in follow-up appointment with complaints of neck and low back pain with associated numbness and tingling that radiates down her right leg into the right foot and also numbness and tingling that radiates down her right arm. She had one transforaminal epidural steroid injection with 50% relief in pain. The pain level has come down to about 4 to 5. There are no other new complaints.

DIAGNOSES:
Lumbar disc herniation.
Lumbar radiculopathy.
Cervical radiculopathy.

RECOMMENDATIONS:
We will schedule the patient for a right L4-L5 transforaminal epidural steroid injection to help reduce the pain. I explained the risks, benefits, and treatment options with the patient. The patient was asked to continue with physical therapy.

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