- Reasons for visit: Patient presents with lower back pain and stiffness.
- Duration/timing/location/quality/severity/context of complaint: Pain has been present for 3 weeks, located in the lumbar region, described as a dull ache with a severity of 6/10.
- List anything that worsens or alleviates the symptoms: Pain worsens with prolonged sitting and is alleviated by stretching.
- Progression: Symptoms have gradually worsened over the past week.
- Previous episodes: Patient reports similar episodes in the past, managed with physical therapy, which provided temporary relief.
- Impact on daily activities: Pain affects the patient's ability to sit for long periods at work.
- Associated symptoms: Occasional tingling in the right leg.
Review of Systems: A 12 point review of systems was performed and was negative except as detailed in the HPI. No fever, chills, productive cough. Occasional tingling in the right leg.
Tests: There are no new laboratory results or radiology reports for review today.
Physical Exam Findings:
-Constitutional: Healthy appearing, well developed, alert, in no acute distress
-Eyes: Conjunctivae clear, sclera anicteric
-Neck: No asymmetry, trachea is midline
-Respiratory: Respirations are even and unlabored, no dyspnea
-Abdomen: Soft, non-distended
-Vascular: Well perfused
-Lymph: No peripheral edema
-Skin: Warm, dry. Head and neck skin with no lesions or rash
-Neurologic: Awake, alert oriented x3; no focal neurologic deficits
-Psychiatric: Judgement and insight intact
-Musculoskeletal: Moves all extremities, No deformity. Able to walk without assistance with normal gait pattern,
Strength 5/5 symmetric b/l LE/LE
DTRs symmetric 2+/4 b/l UE/LE
sensation grossly intact
OMT exam
Head: No significant findings
Cervical: Mild tenderness on palpation
Thoracic: No significant findings
Lumbar: Increased muscle tension and tenderness
Pelvis: No significant findings
Sacrum: No significant findings
Lower Extremity: No significant findings
Upper Extremity: No significant findings
Ribs: No significant findings
Abdomen: No significant findings
AGR 1: Lumbar region
AGR 2: Cervical region
Assessment and Plan:
ASSESSMENT:
Lumbar somatic dysfunction
Cervical somatic dysfunction
PLAN:
“Somatic Dysfunction on display today was most prominently noted in the lumbar region with increased muscle tension and tenderness.
- Therapeutic exercise and HEP reviewed
- Mobility and flexibility exercises were reviewed
- Recommendations for follow-up visits in 3-4 weeks
Procedure Note:
Time In: 10:00 AM
Time Out: 11:00 AM
I reviewed the patient’s prior treatment notes, medication reconciliation, and available imaging studies prior to the procedure. OMT was deemed to be an appropriate and safe intervention.
The patient gave affirmative consent prior to osteopathic manipulation. The risks and benefits as well as the reasonable expectations of treatment were reviewed.
Somatic Dysfunction was identified by the presence of Tissue Texture Abnormalities, Asymmetry, Restriction of motion, and Tenderness (TART) in the following regions;
Head (M99.00), Cervical (M99.01), Thoracic (M99.02), Lumbar (M99.03), Sacrum (M99.04), Pelvis (M99.05), Ribs (M99.08), Upper Extremities (M99.07), Lower Extremities (M99.06), Abdomen and Other Regions (M99.09).
OMT in 7-8 Body Regions (CPT code 98928), OMT in 9-10 Body Regions (CPT code 98929) was performed. The patient responded well to manipulation and suffered no treatment side effects. Positive TART changes were noted post-treatment. The patient expressed relief of symptoms post procedure.
Primary techniques employed during today's procedure were: Osteopathy in the Cranial Field, Stills Indirect Technique, Balance Ligamentous Tension, Facilitated Positional Release and Myofascial Release.
MANUAL THERAPY including LYMPHATIC DRAINAGE TECHNIQUES (CPT:97140) (40 minutes=3 units) were directed at the somatic dysfunction in the appropriate myofascial areas of the lumbar and thoracic area;
with performance of Bobath NEUROMUSCULAR REEDUCATION (CPT:97112) (40 minutes=3 units) spent retraining inhibited muscle groups to fire independently and in concert with other muscles within that firing pattern with a focus on posture, balance and muscle synergy of the spine and lumbar area.
Stretching was directed at the somatic dysfunction in the spine and myofascial areas of the lumbar area with appropriate THERAPEUTIC EXERCISE (CPT:97110) (40 minutes=3 units) Isometric, isotonic, and isolytic resistance was applied during range of motion exercises to help disinhibit, recruit, and retrain muscle groups to promote strength, endurance and flexibility.
-The patient is instructed in HEP, after care per the Plan section above.
-Some discomfort post-treatment is common and should resolve in 3-4 days. We discussed the use of NSAIDS If medically appropriate, magnesium soaks, heat, Ice, and HEP including stretching to assist in disinhibiting restrictive myofascial patterns and furthering goals of care
-We recommend a follow up appointment in 3-4 weeks for reevaluation of the patient's symptoms, response to treatment, and to determine if the treatment interval is appropriate to facilitate the goals of care and progress toward a therapeutic end point. This will guide prognosis and determine need for continued treatment using OMT.
Time spent in the care of this patient today was in excess of 60 minutes independent of any separately billable procedures. This includes preparing for the visit, medically necessary examination, evaluation, patient teaching, counseling, and documentation in the medical record. Greater than 40 minutes was spent face-to-face during this encounter.
Dr. Thomas Kelly, DO
This record was generated with the use of electronic voice recognition and transcription software. Please excuse any transcription errors that may have occurred during the dictation of this note.
PROCEDURE INVOLVED Supervised 1:1 CONCURRENT:
MANUAL THERAPY including LYMPHATIC DRAINAGE TECHNIQUES (CPT:97140) (40 minutes=3 units) were directed at the somatic dysfunction in the appropriate myofascial areas of the abdomen, lower extremities, and thoracic area;
with performance of Bobath NEUROMUSCULAR REEDUCATION (CPT:97112) (40 minutes=3 units) spent retraining inhibited muscle groups to fire independently and in concert with other muscles within that firing pattern with a focus on posture, balance and muscle synergy of the spine and bilateral Lower Extremities.
Stretching was directed at the somatic dysfunction in the spine and myofascial areas of the bilateral Lower Extremities with appropriate THERAPEUTIC EXERCISE (CPT:97110) (40 minutes=3 units) Isometric, isotonic, and isolytic resistance was applied during range of motion exercises to help disinhibit, recruit, and retrain muscle groups to promote strength, endurance and flexibility.
Time spent in the care of this patient today was in excess of 60 minutes independent of any separately billable procedures. This includes preparing for the visit, medically necessary examination, evaluation, patient teaching, counseling, and documentation in the medical record. Greater than 40 minutes was spent face-to-face during this encounter.
