Sacroiliac joint dysfunction

The patient is a 57-year-old female, who was the restrained driver of a vehicle involved in a motor vehicle accident on June 28, 2013. She presents today for further evaluation and treatment of her injuries. Specifically, she reports pain to the low back predominantly on the right side. She does report sharp pains at times, but denies pain, weakness or numbness shooting to her extremities. She does have a history of low back pain, which occurred from a prior motor vehicle accident. However, she reports that low back pain had completely resolved and she was pain-free prior to this new accident. She has been receiving therapies and is seeing a chiropractic physician. She has undergone some trigger point injections, which she reports did provide some relief. She has had an MRI scan of the lumbar spine. This was performed on August 21, 2013. It did reveal a herniated disc at L5-S1.

IMPRESSION:
1. Posttraumatic lumbago.
2. Lumbar herniated disc.
3. Sacroiliac joint dysfunction.
4. Myofascial pain secondary to all the above.

PLAN:
The patient and I did have nice talk today regarding her pain and overall plan of care. She does have patches which were prescribed by Dr. and we will continue to use these for pain relief. She will continue with therapy as well as home exercise. She will use ice 20 minutes at least twice daily. We did discuss other treatment options including additional trigger point injections. She did well from Dr. . We will therefore request pre-certification from her insurance carrier for additional injections. She will call me with any questions or concerns prior to this.

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