Osteopathic Manipulative Treatment: New Patient Example Part II

Source: http://www.md-do.org/omm.htm

SOAP Note - New Patient Example

S
Patient presents with a chief complaint of achy, dull pain in the upper thoracic and lower cervical region, radiating into the posterolateral right arm. Patient has been having stiffness in the morning since then. He states the onset was two days ago, after golfing in cold weather. The symptoms have been gradually increasing since that time. The symptoms are aggravated while driving and working at his computer station; relieved when lying down. He denies anesthesias, parasthesias or weakness in the right fingers, hand or forearm. He has taken Tylenol with minimum relief.

PSH: Denies.

PMH: Noncontributory.

SH: Patient owns an insurance agency and spends several hours per day at a computer keyboard.

FH: Negative for rheumatologic problems.

Present Medications: Tylenol. No known drug allergies.

ROS: Cardiac, pulmonary and GI all negative

O
B/P 122/70

Pulse 64

Respirations 18

Weight 167

Heart has a regular rate and rhythm with no murmurs. Lungs are clear to auscultation bilaterally. Neurologic DTRs are +2/4 in the upper and lower extremities bilaterally. Sensation is intact and there is no evidence of weakness or atrophy in the upper extremities.

Structural Exam: T1 is rotated and sidebent right. C6 and 7 are sidebent left. T3 is rotated right with posterior displacement of the right 3rd rib. There is pain at the end point of range of motion of these areas. There are acute tissue texture changes and muscular hypertonicity in the upper right thoracic and lower cervical paravertebral muscles. Extension of the neck reproduces the patient's symptoms. The lumbar spine is sidebent left with secondary right rotation and significant restriction at the thoracolumbar and lumbosacral junctions. The sacral base declines to the right. 1.) Examination of the shoulders revealed negative impingement test, a negative drop arm test. 2.) The rotator cuff had normal motion both active and passive.

A
1. Somatic dysfunction - cervical, thoracic, costal, lumbar, sacral 739.1, 739.2, 739.4, 739.8.

2. Mild cervical nerve root irritation secondary to #1 above; suspect DJD. 353.2

P
1. OMT to above areas with excellent response.
2. Rx - Lodine 400mg to be taken one b.i.d. with food.
3. Recheck 1 week for signs and symptoms persist.



CODING FOR THIS CASE

Evaluation/management; new patient 99204-25

OMT five body regions; cervical, thoracic, lumbar, sacrum, ribs 98927