Posttraumatic lumbar sprain/strain

The patient is a 45-year-old male who was involved in a slip and fall type injury on August 30, 2012. The reports that he stopped into a hole, which he did not see causing him to injure his back, as well as his knee. The patient reports to me that his knee required a surgical repair on March 2013. I did see an MRI scan report, which was highly suggestive of a medial meniscus tear. The patient also has had an MRI scan of his low back, which revealed a bulging disc at L4-L5. The patient reports pain as well as a burning sensation down his left lower extremity. He reports to me that he has had two epidural steroid injection procedures. He reports that the second procedure did provide some relief but only for about one month. He also reports that he has been prescribed Percocet for his pain. He reports that these are not strong enough due to his significant pain. He also reports that he has physical therapy since this injury first occurred. The patient specifically denies any prior history of back or knee pain prior to this injury.

IMPRESSION:
1. Posttraumatic lumbar sprain/strain.
2. Lumbar radiculopathy.
3. Left knee medial meniscus tear status post surgery.

PLAN:
The patient and I did have a nice talk today regarding his pain and overall plan of care. I had recommended trigger point injection for the patient for his lumbar spine. He will continue with physical therapy and continue with ice and home exercise. I am referring the patient to Dr. for medication management and to discuss further interventional procedures would be appropriate. The patient will call me with any questions or concerns prior to next visit.

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