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| Case 1 - Acute Low Back Pain (new patient) Case 2 - Chronic Neck Pain (established patient) Case 4 - Exacerbation of Asthma Case 5 - Carpal Tunnel Syndrome
New Patient
Subjective A 30 year old male complains of low back pain. It started 2 days ago when lifting some heavy furniture. The patient reports having a sharp pain in his left lower back at the time of lifting. The next morning he was unable to stand straight due to significant pain in low back. Denies numbness/tingling or weakness of lower extremities. He took ibuprofen with mild relief of pain. He has no prior history of back pain/injury. Denies and medical or surgical history. No Allergies to medications.
Objective Vitals BP-130/80, P-72, R-18, Temp 98.8 Osteopathic Exam - focussed
Lumbar ROM: FB 75, BB 10, SBL 30, SBR 20 Ext: no edema. Dec ROM Lower Ext due to pain in lower back. Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, CN II-XII grossly intact
Assessment 1. Lumbosacral sprain 846.0 2. Lumbar Somatic Dysfunction 739.3
Plan 1. OMT, Myofascial, HVLA to Lumbar spine with improvement of pain and range of motion. (Click here for OMT diagrams) 2. Continue ibuprofen as needed for pain 3. Exercises, stretching and Range of motion teaching 4. Follow up in 1 week
E/M: 99204-25 OMT x1 region 98925
Established Patient
Subjective 35 year old male presents to your office for an OMT treatment of his neck pain of 5 years. Reports sometimes starts to get a headache from the tension in the back of his neck. (his history is a car accident 5 years ago with negative imaging results)
Objective Vitals BP-120/75, P-68, R-18, Temp 97.8 Physical Exam - focussed HEENT/neck: NC/AT, pharnyx - benign, Neck supple, No nodes CV: RRR s1 + s2, no murmurs Pulm: Clear to ausc, b/L No R/R/W Abd: soft, NT/ND, + bowel sounds, no masses Osteopathic Exam:
Cervical ROM: FB 70, BB 50, SBL 45, SBR 30, Rot L 80, Rot R 65 Ext: no edema. Dec ROM Lower Ext due to pain in lower back. Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, CN II-XII grossly intact
Assessment 1. Cervical Strain 2. Cervical Somatic Dysfunction 739.1
Plan 1. OMT, myofascial, HVLA to cerivcal spine with improvement of pain and ROM 2. Continue Naprosyn 500mg PRN for pain 3. Stretching exercises given 4. Return to office PRN
E/M: 99211-25 OMT x1 region 98925
Acute Sinusitis (established patient)
Subjective A 27 year old female complains of stuffy nose and sinus pain. Started over 1 week ago with runny nose, continued with increasing pain over sinuses, thick yellow/greenish nasal discharge (with blowing), "draining" down back of throat and mild cough. Pt has a history of sinusitis in the past and typically "gets one" every year. Taking Tylenol Cold and Sinus with mild relief of symptoms. Has been feeling worse lately. Denies fevers, N/V/D. Mild sore throat, HA's, Facial pain, nasal congestion, occasional cough.
Objective Vitals BP 110/60, P-82, R-18, Temp 99.3 HEENT: Eyes - PERRL, EOMI, Anicteric sclera, clear conjunctiva Nose-erythematous turbinates, mild thick nasal discharge Pharnyx - mild erythema post. pharynx, Post nasal drip Ears - TM clear neck: supple, mild anterior cervical lymphadenopathy, mild tender nodes CV: RRR s1+s2, no murmurs/gallops or rubs Pulm: CTA b/L, no R/R/W Osteopathic exam:
A/P 1. Acute Sinusitis - Biaxin x 10days - OTC cough suppressant, Decongestant PRN - OMT to thoracic inlet, including thoracic pump, inhibition over maxillary sinuses, cervical HVLA, soft tissue, myofascial release. - pt responded well to treatment
E/M: 99213-25 OMT x 2 regions (cervical/thoracic) 98925
(T)Tissue texture Changes (A)Asymmetry (R)Restriction of Moton (T)Tenderness
0 - No SD or Background (BG) levels 1 - Obvious TART (esp R and T), +/- symptoms 2 - More than BG levels, Minor TART 3 - Key lesions, symptomatic, R and T stands out | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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