jen11976
Contributor
What would you code the following subsequent hospital visit?
69 y/o f with 6 day hx of low back pain which radiates down L leg. VAS 5-6/10. Radiation down to L knee, occasionally to mid-calf area. No associated numbness/weakness. Currently on Flexaril with no significant relief.
MRI pending. CT scan - multiple disc bulge, facet hypertrophy
PMH: HTN, CAD, s/p stents, CVA x 2
All: Codeine, PCN
Exam: Patient in bed. Left sacroiliac joint tenderness, left piriformis spasm +, single leg raise normal bilaterally, Ext. both normal bilaterally, no significant neuro deficits
Imp: 69 y/o F with acute onset LBP with some radiation down left leg to knee. MRI pending. Sacroiliac pain and Left piriformis spasm.
-Continue conservative care with PT and meds
-Patient may benefit from OSIJ/Piriformis Trigger Point injection
-Not a candidate for epidural due to anticoagulation
-Patient can be followed at our clinic
Any help is greatly appreciated!
Thank you!
69 y/o f with 6 day hx of low back pain which radiates down L leg. VAS 5-6/10. Radiation down to L knee, occasionally to mid-calf area. No associated numbness/weakness. Currently on Flexaril with no significant relief.
MRI pending. CT scan - multiple disc bulge, facet hypertrophy
PMH: HTN, CAD, s/p stents, CVA x 2
All: Codeine, PCN
Exam: Patient in bed. Left sacroiliac joint tenderness, left piriformis spasm +, single leg raise normal bilaterally, Ext. both normal bilaterally, no significant neuro deficits
Imp: 69 y/o F with acute onset LBP with some radiation down left leg to knee. MRI pending. Sacroiliac pain and Left piriformis spasm.
-Continue conservative care with PT and meds
-Patient may benefit from OSIJ/Piriformis Trigger Point injection
-Not a candidate for epidural due to anticoagulation
-Patient can be followed at our clinic
Any help is greatly appreciated!
Thank you!