Follow Up

Your patient was seen for an in-person follow-up visit. They received rehabilitation counselling between 10:00 AM until 11:00 AM. Please find my visit note below. Chief Complaint: Persistent lower back pain History of Presenting Illness: "The patient is a 45-year-old male, who returns to the clinic for a follow-up." The patient is a physically active individual who has been experiencing lower back pain for the past three months. During the previous visit, the patient was advised to begin a home exercise program. Currently, the patient reports mild improvement but continues to experience discomfort, especially after prolonged sitting. Additional information related to the chief complaint includes occasional radiating pain to the left leg. Pertinent Past Medical History: Unchanged Pertinent Medications/Supplements: Ibuprofen 400mg as needed Pertinent Medication Allergies/Intolerances: Unchanged Focused Physical Examination: The examination revealed tenderness in the lumbar region with limited range of motion in flexion and extension. No neurological deficits were noted. Investigations: MRI of the lumbar spine (15 October 2024) showed mild disc bulge at L4-L5 without significant nerve root compression. Procedure: Ultrasound-Guided Lumbar Facet Joint Injection "A discussion was had with the patient regarding therapeutic injection. The risks, benefits, and alternatives associated with the procedure were discussed. This included, but was not limited to, rare complications such as infection, bleeding, neurovascular injury, tendon rupture, allergy, transient hypertension/hyperglycemia, and post-injection flare. The patient provided voluntary, informed verbal consent. The affected area was cleaned in a sterile fashion using chlorhexidine. Based on current best practice, and landmark-based failure, ultrasound guidance was used. The ultrasound probe was covered with Tegaderm and sterile gel was applied to the patient." The patient was positioned prone on the examination table. The ultrasound-guided technique was used to identify the lumbar facet joint on the left side. A 22-gauge needle was used, and aspiration was negative. I used 1% Lidocaine without epi and Depomedrol. The needle was withdrawn, and there were no immediate complications. Impression and Plan: "In summary, clinical history, investigations, and physical examination consistent with a diagnosis of lumbar facet syndrome." The MRI findings, along with the patient's symptoms and physical examination, support this diagnosis. An ultrasound-guided therapeutic injection was successfully performed at today's visit. There were no immediate complications, and post-procedural examination demonstrated a reduction in symptoms. The patient was counseled on post-procedural care including: -Keep the injection site clean and dry. -Ice injection site 10-15 minutes 2-3 times in the first 24 hours. -May take simple analgesics as needed. -Avoid excessive activities for 1-2 days. The patient was counseled on their diagnosis, prognosis, and treatment plan. The following is recommended: -The patient was recommended to begin an active, exercise-based rehabilitation program for stretching and strengthening. They understand that the biomechanical effects of muscle retraining are not realized for several weeks of dedicated participation and progression of exercises. -The patient was recommended to begin a home exercise program for stretching and strengthening the affected areas. Explained that biomechanical effects of muscle retraining are not realized until several weeks of dedicated participation and progression of exercises. Provided a handout of exercises and demonstrated them in the clinic. -Follow-up to be arranged for 6 weeks for reassessment and rehabilitation counselling. "The patient was provided ample opportunity to ask questions and discuss our assessment and treatment recommendations. It was a pleasure participating in the care of your patient. Should you have any questions or concerns, please do not hesitate to contact our office. N.B. The diagnosis and opinions of this report reflect medical writing specifically intended for medical treatment purposes only. This report does not constitute nor is it intended to be used as a functional/residual capacity evaluation, disability index tool, or other legal instrument. Dictated with electronic speech recognition software. Please excuse any transcription errors."