Low back pain below the beltline, left greater than right; highly consistent with sacroiliitis

The patient is a very pleasant 33-year-old TV producer. She states approximately one year ago, she came home from a work-related trip and felt low back stiffness. She states there was no radiating component to the discomfort. She resumed her usual workout sessions and was able to work through the stiffness and slowly work her way back to exercise regularly. She ultimately sought treatment from a spine surgeon who recommended a lumbar MRI and that MRI was found to have minimal changes. She has undergone course of physical therapy and acupuncture and has overall been able to deal with the discomfort up until approximately one month ago. One month ago, she woke up from restless sleep and developed pain from the low back into the left buttocks. She has been noticing paroxysmal epicritic-type pain to the anterolateral distal lower extremity without shooting into the foot. These paresthesias have been waxing and waning over the past month. She presents today for evaluation.

ASSESSMENT:
This is a 33-year-old female television producer who does a lot of traveling with a one-month worsening of her low back pain, well below the beltline, left greater than right with paroxysmal radiating component on the left side.

IMPRESSION:
1. Low back pain below the beltline, left greater than right; highly consistent with sacroiliitis.
2. Left lower extremity paresthesia; true radicular pain versus referred from the SI joint; in light of essentially negative MRI from September 14, 2012.

PLAN:
I had a lengthy visit with the patient today. We discussed taking wait and see approach versus medication management versus further physical rehabilitation modalities versus further diagnostic studies versus surgical referral versus diagnostic, and hopefully therapeutic interventional pain treatment options.

I would like to move very conservatively here and I will start on a course of Celebrex 200 mg daily for the next month. I will give her Valium 2 mg one p.o. q.12h p.r.n. pain secondary to spasm and hopefully this will help with her discomfort during sleep.

Ultimately, she will have to decide if she would like to continue with her physical rehabilitation modalities or if she would like to try to treat this problem directly. My recommendation at this point is that if she feels that she has maximized her conservative physical rehabilitation options, directed sacroiliac joint injection under fluoroscopic guidance could be both a diagnostic and therapeutic modality. The procedure was explained in detail and she voiced her understanding.

She will forward to me the copy of the MRI study from Westside Radiology Associates, so I can view the films myself. If I am not in be at Advanced Wellness office at the time of conversation, I will speak to her while I am back in Nevada. She was fine with that.

Otherwise, she will contact me if she has any changes in her condition or if she has any concerning side effects to the medications at this time. She seemed very happy with the visit today and I look forward working with her.

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