XXXXXXXX Chiropractic Clinic XXXXX
INITIAL EVALUATION PATIENT NAME: XXXXXXXXXX
DATE OF BIRTH: 09/01/1958
The above-captioned patient was seen today for the purpose of initial consultation, examination and evaluation.
SYMPTOMS
The patient reports the following complaints. MID BACK PAIN
This symptom came on gradually. It has not changed since it started. The intensity of this complaint is moderate; meaning it inhibits activity. This complaint is frequent or occurs 50% to 80% of the time. On a scale from 0 to I 0 , with IO being the highest possible level of pain, patient graded the pain as 6. Patient describes the feeling associated with this complaint as dull, aching, and spasmodic. It appears in the morning and is further aggravated in the afternoon. Aggravated by bending to the left, twisting left, and standing. Brought on by bending back, lifting, and sitting. Relieved by bending forward, twisting right, heat, resting, lying down, and medications. Radiates to both shoulder blades.
LOWER BACK PAIN
This symptom came on gradually. It is progressively getting better. The intensity of this complaint is moderate; meaning it inhibits activity. This complaint is frequent or occurs 50% to 80% of the time. On a scale from Oto 10, with 10 being the highest possible level of pain, patient graded the pain as 6. Patient describes the feeling associated with this complaint as dull, shooting, spasmodic, and throbbing. Located postero-laterally, on the both sides. It appears in the morning and is further aggravated in the afternoon. Aggravated by bending to the left, twisting left, standing, and sitting. Brought on by bending back and lifting. Relieved by bending forward, twisting right, heat, resting, lying down, and medications. Radiates to left hip, left leg, and left foot. It also radiates to left sacroiliac joint, left buttock, left hamstring, left calf and left foot.
HIP
This symptom came on gradually. It has not changed since it started. The intensity of this complaint is mild- moderate. The frequency of this complaint is occasional or occurs 25% to 50% of the time. On a scale from Oto 10, with 10 being the highest possible level of pain, patient graded the pain as 5. Patient describes the feeling associated with this complaint as dull, spasmodic, and throbbing. Located postero-laterally, on the left side.
LEFT LOWER EXTREMITY
This symptom came on gradually. It has not changed since it started. The intensity of this complaint is mild- moderate. The frequency of this complaint is occasional or occurs 25% to 50% of the time. On a scale from Oto 10, with 10 being the highest possible level of pain, patient graded the pain as 4. Patient describes the feeling associated with this complaint as shooting, numbing, and tingling. Located postero-laterally, on the left side.
Aggravated by bending to the left and straining. Brought on by twisting left, standing, and sitting. Relieved by bending forward, lying down, and medications. Radiates to left leg and left foot.
NECK PAIN AND CRACKING IN NECK
This symptom came on gradually. It has not changed since it started. The intensity of this complaint is mild- moderate. The frequency of this complaint is occasional or occurs 25% to 50% of the time. On a scale from 0 to 10, with 10 being the highest possible level of pain, patient graded the pain as 4. Patient describes the feeling associated with this complaint as dull and aching. It appears in the afternoon. Brought on by sitting. Radiates to both shoulders. It also radiates to head, left shoulder blade, and left shoulder.
PAST MEDICAL HISTORY • Hernia inguinal 3 years ago. • Left elbow surgery as a child. • Kidney stones.
PAST FAMILY HISTORY • Pancreatic cancer (father). PAST SURGICAL HISTORY • Tonsillectomy in childhood. • Left elbow surgery.
ALLERGIES • *None.
SOCIAL HISTORY
Mr. XXXXX reports the use of alcohol and caffeine. PHYSICAL EXAMINATION
The patient's vital signs are: • Height: 6'0"
· Weight: 235 LBS • BMI: 31.87
• Respiratory Rate: 15 RPM
· Pulse: 83 BPM
General/Constitutional: Mr. XXXXXXX is 61 years old. He is overweight for his build. Functional status: No impairment. Gait: Ataxic to right.
Posture: Rounded shoulders, high left shoulder, and antalgic to right. MUSCULOSKELETAL EXAMINATION
THORACIC SPINE
There was tenderness to digital palpation and muscle tension on both sides of the thoracic spine. There was muscle hypertonicity present on both sides of the thoracic spine. There was muscle spasm present on both sides of the thoracic spine. Edema and swelling are noted on both sides of the thoracic spine. Digital palpation for trigger points was positive in the
thoracic area. Multiple active trigger points are stimulated with moderate digital pressure to the thoracic muscles and are associated with consistent referred pain. Trigger points are located on parathoracic bilateral, teres major bilateral, teres minor bilateral, and rhomboid bilateral.
Subluxations are noted at the following levels: T8, T9, Tl 2. LUMBAR SPINE
There was tenderness to digital palpation and muscle tension on both sides of the lumbar spine. There was muscle hypertonicity present on both sides of the lumbar spine. There was muscle spasm present on both sides of the lumbar spine. Edema and swelling are noted on both sides of the lumbar spine. Digital palpation for trigger points was positive in the lumbar area. Multiple active trigger points are stimulated with moderate digital pressure to the lumbar muscles and are associated with consistent referred pain. Trigger points are located on paralumbar bilateral, thoraco-lumbar fascia bilateral, and quadratus lumborum bilateral. Subluxations are noted at the following levels: L5 and sacrum.
HIPS
There was tenderness to digital palpation and muscle tension on the left hip. There was muscle hypertonicity present on the left hip. There was muscle spasm present on the left hip. Edema and swelling are noted on the left hip. Digital palpation for trigger points was positive in the hips. Multiple active trigger points are stimulated with moderate digital pressure to the hip muscles and are associated with consistent referred pain. Trigger points are located on left gluteus maximus, left gluteus medius, and left iliopsoas. Subluxations are noted at the following levels: Pelvis on the left and right posterior innominate (RPIN). LOWER EXTREMITIES
There was tenderness to digital palpation and muscle tension on the left lower extremity. There was muscle hypertonicity present on the left lower extremity. There was muscle spasm present on the left lower extremity. Edema and swelling are noted on the left lower
extremity. Digital palpation for trigger points was positive in the lower extremities. Multiple active trigger points are stimulated with moderate digital pressure to the lower extremities muscles and are associated with consistent referred pain. Trigger points are located on left popliteal fossa, left semitendinosus, left semimembranosus, left soleus, and left
gastrocnemius. Subluxations are noted at the following levels: Left posterior greater trochanter, right MCL, Left knee external tibia.
CERVICAL SPINE
There was tenderness to digital palpation and muscle tension on both sides of the cervical spine. There was muscle hypertonicity present on both sides of the cervical spine. There was muscle spasm present on both sides of the cervical spine. Edema and swelling is noted on both sides of the cervical spine. Digital palpation for trigger points was positive in the
cervical area. Multiple active trigger points are stimulated with moderate digital pressure to the cervical muscles and are associated with consistent referred pain. Trigger points are located on left levator scapulae, left trapezius, and left infraspinatus right levator scapulae. Subluxations are noted at the following levels: Cl on the left, C5.
RANGE OF MOTION
• Cervical Spine: Ranges of motion were moderately reduced with pain. Cervical Flexion is 36/50. Cervical Extension is 44/60. Cervical Lateral Right is 40/45. Cervical Lateral Left is 32/45. Cervical Rotation Right is 72/80. Cervical Rotation Left is 60/80. Patient states pain on extension, lateral bending on the left, and rotation on the left.
· Thoracic Spine: Ranges of motion were moderately reduced. Thoracic Flexion is 42/60. Thoracic Extension is 14/20. Thoracic Lateral Right is 24/40. Thoracic Lateral Left is 34/40. Thoracic Rotation Right is 18/30. Thoracic Rotation Left is 24/30. Patient states pain on rotation on the right, lateral bending on the right, and extension.
• Lumbar Spine: Ranges of motion were moderately reduced with pain. Lumbar Flexion is 58/60. Lumbar Extension is 20/25. Lumbar Lateral Right is 20/25. Lumbar Lateral Left is 18/25. Lumbar Rotation Right is 20/45. Lumbar Rotation Left is 22/45. Patient states pain on extension, rotation on the right, and lateral bending on the right.
• Hips: Ranges of motion were within normal limits for the right hip and moderately reduced with pain for the left hip. Right hip flexion is 102/120. Left hip flexion is 114/120. Right hip extension is 18/30. Left hip extension is 24/30. Right hip adduction is 16/25. Left hip
adduction is 20/25. Right hip abduction is 28/45. Left hip abduction is 38/45. Right hip internal rotation is 26/35. Left hip internal rotation is 28/35. Right hip external rotation is 28/45. Left hip external rotation is 34/45. Patient states pain on internal rotation on the left, adduction on the left, abduction on the left, extension on the left, and flexion on the left. • Knees: Ranges of motion were within normal limits for the right knee and mildly reduced for the left knee. Right knee flexion is 134/140. Left knee flexion is 120/140. Right knee extension is 2/0-2. Left knee extension is 0/0-2. Patient states pain on extension on the left.
ORTHOPEDIC SIGNS CERVICAL TESTS
Maximal Cervical Compression Test: Maximum Cervical Rotary Compression with the patient passively rotating, laterally bending and extending the head, while the Doctor waits and watches for the patient's response, was positive on the left and negative on the right. A positive result of spinal pain or radicular pain on the opposite side of rotation may suggest muscular strain in the cervical spine.
Shoulder Depression Maneuver: Positive on the left and negative on the right. Flexion of the head away from affected area while compressing patient's shoulder to point of pain. A positive sign may indicate adhesions of the nerve roots of dural sheath.
Distraction Test: Manual traction of the neck was positive. An increase in pain may indicate a musculo- ligamentous injury. A decrease in pain may indicate nerve root compression. LUMBAR TESTS
Kemp's Test: Kemp's test was positive on both sides. A positive result of localized non-radiating low back pain as the patient extends and rotates the trunk may suggest vertebral facet or pericapsular inflammation.
Observation: The patient can walk on heels and toes. SHOULDER TESTS
Drop Arm Test: Negative on both shoulders. Inability to slowly lower abducted ann. Positive may indicate right and left rotation cuff tear.
Shoulder Apprehension Test: Negative on both shoulders. Positive sign is shoulder pain with a look of apprehension, possibly indicating a shoulder dislocation.
Yergason's Test: The patient attempts elbow flexion and supination against Doctor's
resistance. Positive sign is pain on the anns, possibly indicating bicipital tendinitis. Negative on both sides.
Supraspinatus Press Test: Positive sign is weakness or pain to perfonn this test on the left arm. May indicate rotator cuff/supraspinatus tear. Negative on the right arm.
SACROILIAC TESTS
Yeoman's Test: Pain deep in the SI joint on the left, possibly indicating sprain of the anterior SI ligaments. Negative on the right. The Doctor exerts pressure downward over the affected SI with one hand while flexing knee and hyperextending the hip.
HIP TESTS
Patrick's FABERE (Hip) Test: Pain in left hip, possibly indicating anterior hip joint lesion. Negative on the right. The Doctor places the heel of the affected leg over the opposite knee
and allows the knee of the affected leg to drop to the table. The Doctor applies pressure on the affected knee downward.
KNEE TESTS
McMurray Test: Negative on both knees. Internal and external rotation of the knees causing a "clicking" is a positive sign, possibly indicating a meniscus tear.
A-P Drawer Test: Negative on both knees. An anterior and posterior pulling of the tibia producing an increase in gapping of the knees. An increase in gapping on pulling of the tibia may indicate anterior cruciate ligament tear. An increase in gapping on pushing of the tibia may indicate a posterior cruciate tear.
Lachman's Test: Negative on both knees. An anterior and posterior pulling of the tibia producing an increase in gapping with the knees at 30 degrees of flexion. An increase in gapping on pulling of the tibia may indicate anterior cruciate ligament tear. An increase in gapping on pushing of the tibia may indicate a posterior cruciate tear.
NONORGANIC SIGNS
Libman's Sign: Negative on both sides. Positive sign provides an indication of the patient's pain threshold. The Doctor applies increasing pressure with the thumb on the mastoid process. Waddell's Signs: Negative. Based on the following
component tests results: Distraction - Negative
Waddell's nonorganic pain signs are objective measure for evaluation of abnonnal psychological issues. When a
sign consists of two tests, it is not necessary for both tests to be positive to result in a positive sign. When three or more of the five signs are positive, nonorganic low back pain must be considered, and the psychological issues clinically addressed.
NEUROLOGICAL EXAMINATION REFLEXES
The deep tendon reflexes were evaluated and graded using the Wexler scale. (0 = absent with reinforcement, 1+
= hypoactive, 2+ = nonn al, 3+ = hyperactive, 4+ = hyperactive with transient clonus, 5+ = hyperactive with
sustained clonus.)
• The upper and the lower extremities reflexes were tested and found to be 2+ bilaterally. DERMATOMES
The upper extremities dermatomes were tested and found to be within normal limits.
LS: Pinwheel testing of the LS dermatome on the left demonstrated decreased sensation when compared to the opposite side. Numbness is present on left lateral calf region.
X-RAY RESULTS
Lumbar radiographs taken on 09/24/2019 reveal severe degeneration and spondylosis (enclosed) MRI RESULTS
Lumbar Spine AP-Lateral
This request is pending Mr. XXXXXX’s progress or lack thereof. DIAGNOSIS
• (MS4.6) Pain in thoracic spine. • (MS4.S) Low back pain. • (MS4.32) Sciatica, left side.
• (M70.72) Other bursitis of hip, left hip. • (MS4.2) Cervicalgia.
• (M7S.02) Adhesive capsulitis of left shoulder. SUPPORTS
• Lumbosacral support. TREATMENT
Treatment today consisted of the following procedures and therapies: • E/M Office/outpat visit, est, level 2, FFS (99212).
• Chiropractic adjustment (CMT), spinal, 3-4 regions (98941) by way of Specific Diversified Technique at Cl , CS, T8, T9, Tl 2, LS, pelvis on the left, and sacrum.
• Chiropractic adjustment (CMT), extraspinal (98943), to the left shoulder, left hip and left knee. • Therapeutic exercises (97110) were performed for the left shoulder and left hip by way of range of motion and stretching. He completed 3 sets of 8 for 10 minutes of work.
• Mechanical traction (97012) was applied to the lower mid back, low back, mid back, and sacrum for 10-12 minutes.
• Hot/cold packs (97010) applied to the lower mid back, low back, and sacrum for S minutes. • Radiologic exam, spine, lumbosacral 2-3 views (72100).
RADIOLOGY REPORT
Patient's Name: XXXXXX
DOB/Age and Sex: 09/01/1958 male Date of Exam: 09/24/2019
Referring Practitioner: Dr. XXXXXXX Symptomatology:Severe low back pain Findings:
AP and lateral lumbar x-ray views were submitted for an over-read report. The series is technically limited. Reactive osseous change consistent with degenerative stress is visualized at T10-S1. The LS transverse processes are hyperplastic when compared to the adjacent vertebrae. lntervertebra l foraminal narrowing is appreciated at L3 and L5. lntervertebral disk thinning is observed at L1, L3, and L5.
A right list of the lumbar spine with a dextrorotatory scoliosis at L3 (12°) is evident, vertebral retrolisthesis is noted at L3 and L5, the lumbar lordotic angle is 61°, the lumbosacral disk angle is 26°, and minimal pelvic unevenness is noted with the low side on the right.
Conclusions:
1. Lumbar segmental dysfunction/chiropractic subluxation, retrolisthesis of L3 and Ls, right list with a dextrorotatoryscoliosis at L3, and an abnormal lumbosacral level ogenic spondylos1s at L3, disk thinning at L1 and LS, facet arthrosis at L3-S1, and probable intervertebralforaminal narrowing at L3 and L5
2. Thoracic segmental joint dysfunction/chiropractic subluxation and spondylosis.
Thank you for giving us the opportunity to provide this over-read report. Dictated by XXXXXXXX on September 27, 2019
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GOALS AND RECOMMENDATIONS
•His Functional rating Index (FRI) taken today is 70% which categorizes him as severely disabled. Virtually every area of his life has been affected. We will repeat this test in 6-8 visits.
• Treatment goals: have the patient able to ADL's without pain within 6-8 weeks. • Treatment goals: reduce pain by 20% within 6-8 weeks.
• Chiropractic adjustment (98941) will be administered to the neck, upper mid back, mid back, lower mid back, low back, and sacrum due to findings of segmental dysfunction. This will influence joint and neurophysiological function. Treat for the next 6-8 weeks visits and then re-evaluate.
• I recommend this patient have X-Rays taken of his low back and sacrum to determine the presence of pathologies.
• Therapeutic exercises (97110) will be administered for the next 6-8 visits due to decreased
function. Stretching, free weights, and/or surgical tubing will be used to develop an increase in range of motion and strength of the left hip and shoulder 10 minutes per visit.
• Manual extremity muscle manipulation (98943) will be administered to the left shoulder, left hip, and left knee due to hypertonicity, inflammation and pain in order to release muscle tension, break up adhesions, and increase blood flow.
• Mechanical traction (97012) will be applied to the mid back, lower mid back, low back, and sacrum for the next 6-8 visits due to the finding of compressed nerve roots in order to elongate the spinal segments and decompress nerve.
• Ice/Hot packs (9701 will be applied to the lower mid back, low back, and sacrum due to
inflammation found in the exam. This will help decrease the inflammatory response and influence healing. Treatment will be administered for the next 10-12 visits.
•Mr. XXXXXX has been advised to perform only light work duties until his condition has subsided and further evaluations can be performed following this course of treatment.
• Reexamination today (99212). Return 10/03/2019. Sincerely,
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DAILY NOTE PATIENT NAME: XXXXXXXXXXXX
DATE OF BIRTH: 09/01/1958 DATE OF SERVICE: 10/03/2019
Mr. XXXXXXXX reported some improvement in symptoms since last visit. SUBJECTIVE
The patient complained of the following symptoms today:
• Mid back pain: moderate, frequent, remains unchanged since last visit, complaint grade 4 on a scale from Oto 10.
• Lower Back Pain: mild-moderate, occasional, getting better since last visit, complaint grade 5 on a scale from 0 to 10.
• Left Hip: mild, intermittent, getting better since last visit, complaint grade 3 on a scale from Oto 10.
OBJECTIVE
Examination today revealed the following positive findings:
• Neck, upper mid back, mid back, lower mid back, low back, and sacrum exhibits Range of Motion abnormality (hypomobile relative to patient) of moderate degree.
• Myospasms of the thoracic area. This finding has not changed since last visit.
• Tenderness to palpation over the lumbar area. This finding has improved since last visit. • Restricted cervical Range of Motion. This finding has decreased since last visit.
• Spinal fixation(s) noted at Cl, C5, Cl on the left, TS, T6, T9, Tl2, L5,sacrum, and pelvis on the left have decreased his prior treatment.
• Edema of the left shoulder. DIAGNOSIS
The patient's diagnosis remains the same as previously reported. GOALS AND RECOMMENDATIONS
• Chiropractic adjustment (98941) will be administered to the neck, upper mid back, mid back, lower mid back, low back, and sacrum due to findings of segmental dysfunction. This will influence joint and neurophysiological function. Treat as prescribed. visits and then re-evaluate.
• Extremity adjusting (98943) will be applied to the left shoulder and left hip due to hypertonicity in order to stimulate muscle contraction and break up muscle spasm and tissue adhesions. Treatment will be administered as prescribed visits.
• Therapeutic exercises (97110) will be administered as prescribed visits due to decreased function. Stretching, free weights, and/or surgical tubing will be used to develop an
increase in range of motion and strength of the left shoulder, neck and left hip. • Mechanical traction (97012) will be applied to the lower mid back, low back, and sacrum as prescribed visits due to the finding of compressed nerve roots in order to elongate the spinal segments and decompress nerve roots.
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• Ice/Hot packs (97010) will be applied to the low back and sacrum do to inflammation found in the exam. This will help decrease the inflammatory response and influence healing. Treatment will be administered as prescribed for the next 10-12 visits. visits. ASSESSMENT
Mr. XXXXXXX responded favorably to his treatment today and is progressing as expected.
• Based on today's subjective and objective findings, as well as previous encounters, I have a reasonable expectation XXX will experience additional functional improvement with continued treatment.
• The patients pain scales are decreasing, in the lower back from 6 to 5 and the left hip from 5 to 3 since the last visit.
• Today I reviewed the patients lumbar x-rays and let him know that his lumbar spine is seriously injured and has severe disc degeneration and facet arthrosis which is quite severe.
PLAN
Treatment today consisted of the following procedures and therapies:
• Hot/cold packs (970 I 0) applied to the lower mid back, low back, and sacrum for 5 minutes. • Chiropractic adjustment (CMT), spinal, 3-4 regions (98941) by way of Specific Diversified Technique at Cl , CS,TS, T9, Tl 2, L5, pelvis on the left, and sacrum.
• Chiropractic adjustment (CMT), extraspinal (98943), to the left shoulder, left hip and left knee. • Therapeutic exercises (97110) were performed for the left shoulder and left hip by way of range of motion and stretching. He completed 3 sets of 8 for IO minutes of work.
• Mechanical traction (97012) was applied to the lower mid back, low back, mid back, and sacrum for I0-12 minutes.
Patient is to return on 10/09/20 Sincerely, XXXXXXX, D.C.
