Osteopathic Manipulative Treatment: Established Patient Example Part III

SOAP Note - Established Patient Example

S
Patient continues to experience achy and dull pain in the right lower cervical region, particularly with extension of the neck. It continues to radiate into the right lateral arm. He has experimented with some different positions of his car seat, which he feels has been helpful. He has tolerated the Lodine well and states that overall he fees somewhat improved. Further work history reveals improper placement of video screen at computer station and lack of wrist rest at keyboard.

O
B/P 126/64

Pulse 64

Respirations 18

Cardiac and pulmonary exam again negative. DTRs are +2/4 in the upper extremities bilaterally. No weakness or atrophy in the upper extremity. Tl and T3 are again rotated right with right 3rd rib dysfunction and hypertonicity of the right rhomboid muscles. The lower cervical segments are again sidebent left with tightness of the short restrictor muscles on the right. The lumbar spine is in better balance today with level sacral base. X-rays taken in the office today reveal an uncovertebral osteophyte at the C5-6 level on the right, causing mild foraminal narrowing. Radiologist report pending.

A
1. Somatic dysfunction - cervical, thoracic and costal, with secondary muscular

Hypertonicity. 728.8, 739.1, 739.2, 739.8

2. DJD cervical spine, 721.0

3. Mild cervical nerve root irritation 353.2

Secondary to #1 and 2 above.

P
1. OMT to above areas with good mobilization.

2. Continue Lodine,

3. Recommend changes in work station configuration,

4. Re-evaluate in 1 week.



CODING FOR THIS CASE

Evaluation/management; established patient 99214-25

OMT three body regions; cervical, thoracic, ribs 98926