Osteopathic Manipulative Treatment: Established Patient Example Part II

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

SOAP Note - Established Patient Example

S
Patient ambulating, non-smoker with chief complaint of deep cough and with occasional vomiting, x three weeks. Onset nasal congestion; hoarseness; cough; low grade temperature (100-101 degrees). Almost dry cough with occasional clear sputum. Pain in center chest with coughing and no radiation of chest pain. Patient did have right rib pain with deep inspiration and cough. Cough worse in PM with occasional insomnia. Occasional slight chills and sweats.

O
Temperature = 100 degrees; blood pressure = 120/80; pulse = 92; respiration = 18. Chest- diffuse insp. rales (fine and course). Heart - RRR without murmur. H& ENT - nasal congestion with TMs non--injected; pharynx-injected with cervical lymphadenopathy. Abdomen - non-tender, no splinting, negative Lloyds. Structural exam - resp diaphragm amplitude diminished with lateral rib restrictions R>L.

Sternal tenderness with palpation

T6-L1 (N) SBRRL

C3-7 SBRRRAA RR OA SBRRL

Tentorium restricted with CRI

A
1. Pheumonia, prob mycoplasma 483.0

Somatic Dysfunction - head cervica, 739.0, 739.1, 739.2, 739.8, 739.9 thoracic, lumbar, rib cage, abdomen regions
3. Strained anterior cervical fascia

P
Treatment plan - Erythromycin 250 mg qid x 2 wks

Tessalon Perles: Two tablets q 6-8 hrs prn

Lab - CxR, CBC with diff, cold agglutinins

OMT - head, cervical, thoracic, lumbar, rib cage, abdomen regions (soft tissue and HVLA)

Lymphatic pump; rib raising

Call in 24 hrs; return in one wk for re-eval.



CODING FOR THIS CASE

Evaluation/management; established patient 99214-25

OMT, five to six body regions 98927