This is a 48-year-old female with an 11/21/2013 date of injury, due to an altercation where she was shoved by a patient while working as a dental assistant.
DIAGNOSIS: Chronic Right SI Joint Pain
12/01/15 Progress Report described a follow-up visit. The patient is status post left sacral iliac joint fusion on 09/04/15. She has 0 pain on the left after surgery. Now, she has pain on the right side but it is not as severe. It has however, been disabling for her. Current medications include Baclofen, Percocet, flexeril, Norco, Progesterone and Colace. Plan: refer the patient back to Dr. Hembd for a right sacroiliac joint injection. Is she responds she would be a candidate for a minimally invasive sacroiliac joint fusion on the right side. Follow up is in 2 months.
10/12/15 Progress Report documented that the patient is doing good post her sacroiliac joint fusion. She has occasional pain on the right side. Treatment plan included discontinuation of walker. …show more content…
Her symptoms were identified to be related to SI joint pathology following a left-sided SI joint block which almost completely resolved her pain symptoms. Her symptoms had returned in the interim and she recently had an evaluation with Dr. Schrot who indicated that she was a good candidate to the SI joint. The pain was described as a stabbing sensation across the lower lumbar spine primarily located over the PSIS. There was no radicular pain or numbness. The pain was rated at 8/10. The treatment plan included surgery and continuation of Norco, Flexeril, and