compression fracture

The patient is a pleasant elderly female here for followup visit for her chronic low back pain. After last trigger point injection and with the help of physical therapy, the patient’s pain is about 50 to 60% better. The patient is very pleased with it. The patient recently had an x-ray of the L-spine, which showed a new compression fracture involving the vertebral body of T9, which was noted on the lateral level of the chest dated September 2011. The patient denies any weakness, denies any tingling or numbness down the leg. She is on Evista for osteoporosis and is being followed by her medical doctor. Otherwise, there are no other changes in her past medical history, social history since her last visit.

DIAGNOSES:
Osteoporosis.
Myofascial pain syndrome.
Lumbago.
T9 compression fracture.

RECOMMENDATIONS:
I discussed the case with physical therapy and we will continue with gentle physical therapy as it seemed to the help the patient and the patient followup with the medical doctor for further management of osteoporosis. I also explained to her daughter about T9 compression fracture. We will continue with the current management. If the patient’s pain gets worse, the patient will be a candidate for another trigger point injection.

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