ESL Pain Management Sample

DIAGNOSIS
Low back pain with left lower extremity numbness, lumbar disk herniation, lumbar foraminal stenosis.

A 55-year-old white female who underwent sacroiliac joint injection, right, with 80% improvement in right-side low back pain.

The patient now presents to the pain clinic with left lower extremity pain and numbness. The patient’s MRI shows foraminal stenosis, L4-5 left. We decided to proceed with a lumbar epidural steroid injection.

PLAN
If patient is doing well, no further intervention will be done.