Download Medicare Notes of an Actual Patient

Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 19, 2016
CHIEF COMPLAINT:
Iris presents with a chief complaint involving her lower lumbar and sacral region, left sacroiliac region and left
anterior hip and groin.
ONSET OF SYMPTOMS
Iris states this began to bother her over the past 2 weeks after sitting at nursing home.
Prior interventions or treatments, including medications - None
Iris was asked to describe this complaint with a few short sentences. This is what she said; sharp, shooting
pain in my lower back goes into my hips and keeps me from being active
HISTORY OF CURRENT PROBLEM
Iris states that she has had trouble with these same complaints in the past and that this is a recurrent problem
and has been for years.
FUNCTIONAL ASSESSMENT
Iris rates this pain on the 0-10 VAS scale as a 5/10/10This bothers her constantly, or 100% or the day and
night, over her lower lumbar and sacral region, left sacroiliac region and left anterior hip and groin.
Iris states that the problem radiates into her left sacroiliac region and left anterior hip and groin.
REVIEW OF SYSTEMS
Normal and unremarkable. No bone pain, falls, fractures, focal neurologic deficits, nausea, vomiting, coughing
or vomiting blood, bloody or tarry stool, hematuria, difficult or painful swallowing, chest or abdominal pain,
weight loss, unexplained fever, or pyogenic infection.
PRESENT
- Hypertension or high blood pressure.
- Diagnosis and treatment of cardiovascular disease.
- Autoimmune type arthritic disease.
- History of significant episodes of lower back pain.
- Diagnosis and treatment of allergies.
OBJECTIVE
P. A. R. T. EVALUATION - (Pain/Tenderness, Asymmetry/Misalignment,Range of Motion Abnormality,
Tissue/Tone)
PAIN/PALPATION - Improvement noted as Iris reports less pain with palpation today over her
PAIN WITH PALPATION - Iris reported pain with palpation over her lower thoracic and upper lumbar region,
lower lumbar and sacral region, left sacroiliac region and left posterior thigh.
ASYMMETRY AND POSTURE ABNORMALITIES - While observing Iris's posture today I noted she has
anterior pelvic rotation when viewed laterally.
MISALIGNMENT/ASYMMETRY - Misaligned vertebrae with associated segmental dysfunction including
asymmetry, tenderness, and hypertonicity noted at T11, T12, L3, L4, L5 and sacrum.
LIMITED/RESTRICTED RANGE OF MOTION -she has limited and restricted range of motion in the joints of
Iris Stegmaier
(DOB : Jan 06, 1935)
Page 1
Dec 19, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 19, 2016
her lower lumbar and sacral region.
TISSUE AND TONE - Palpation of her soft tissues today revealed hypertonicity, spasm, active trigger points,
and inflammation in the region of her lower thoracic and upper lumbar region, lower lumbar and sacral region,
left sacroiliac region and left posterior thigh.
EXAMINATION FINDINGS:
>Dejerine's Triad was normal and did not increase or produce pain. This test is a three-part test for
determining nerve compression which can arise from osseous foraminal encroachment, disc protrusion
(bulging), prolapse (herniation) or severe sprain/strain of the spine. Pain may be reported with coughing,
sneezing, or bearing down as if trying to have a bowel movement.
>Straight leg raise (SLR) was positive for pain on her left side prior to 90 degress of passive leg extension.
>Kemp's test was negative bilaterally and did not produce local or increased lower back pain.
>Gillet test was positive on her left side indicating abnormal movement of the left sacroiliac joint.
>Patrick's test or FABER test (for Flexion, Abduction and External Rotation) was negative bilaterally as
performed to evaluate pathology of the hip joint or the sacroiliac joint.
>Lumbosacral stress test was positive on her left and right side and is indicitive of posterior joint involvement
in the lower lumbar motor units suggesting generalized musculoligamentous involvement of the lumbar spine
and suggests strain/sprain.
>Valsava's was negative for pain.
>Piriformis press test was positive for a tight left piriformis muscle.
>Minor's sign was present with difficulty on both her left and right sides and is often observed in patients with
low back conditions in which supporting the low back is necessary in order to rise from a seated position. This
test is indicative of sciatica, sacro-iliac lesions, lumbosacral lesions, and/or disc involvement.
>Slump test was positive on the left for signs of adverse mechanical neuromeningeal tension (AMNT).
>Low back hyperextension test was positive bilaterally for the presence of a low back lesion.
>Heel walk was difficult to perform on her left side suggesting L4-5 nerve root irritation.
>Toe walk was difficult to perform on her left side suggesting L5-S1 nerve root irritation.
>Ely's test was abnormal on her left side suggesting muscle tightness and/or neurological lesions.
RADIOLOGY
Outside Views Taken on 12/13/2016 From ADR Reviewed Today:
Thoracic Series, 2 Views, AP and Lateral
Lumbar, 2 View, AP and Lateral
Degenerative joint disease
Loss of disc height (spondylosis) at L4-L5 and L5-S1
IMPRESSIONS
Biomechanical issues as outlined above.
Chiropractic care is recommended.
ASSESSMENT
CURRENT DIAGNOSIS
Iris Stegmaier
(DOB : Jan 06, 1935)
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Dec 19, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 19, 2016
- Lumbago with sciatica can be the result of tiny strains or tears of some of the small muscles and ligaments
of the lower lumbar spine. Arthritis of the facet joints, a prolapse of an intervertebral disc, or deformation or
changes of the normal spine curvature can produce pain across the lower part of the back that radiates into
the thigh or leg indicating irritation of the sciatic nerve in her lower thoracic and upper lumbar region, lower
lumbar and sacral region, left sacroiliac region, left posterior thigh, posterior left knee, left posterior leg and left
posterior heel at the achilles tendon insertion.
- Spondylosis or spinal degenerative changes (osteoarthritis) such as bone spurs and degenerating
intervertebral discs at L4, L5 and sacrum.
- Intervertebral disc degeneration with pain, and at times radiating weakness or numbness, stemming from a
degenerated disc in her spine at L4, L5 and sacrum.
- Subluxation complex is a Medicare required diagnosis term that when used in the chiropractic profession
defines a spinal vertebra that is misaligned from its normal positioning, which in turn is interfering or distorting
normal nervous system functionality, and is identified according to Medicare requirements at L4, L5, T11, T12
and sacrum.
- Spinal enthesopathy, occurring at the level of a tendon or a ligament’s insertion on the bone in the lower
thoracic and upper lumbar region and lower lumbar and sacral region.
- Muscle spasm in her muscles of the left lumbar area and left gluteal region.
- Pain in joint of her left anterior hip and groin.
TREATMENT TIME TO REACH MAXIMUM IMPROVEMENT
Iris is expected to reach maximum medical improvement (MMI) within the next 2 months.
PROGNOSIS:
Iris's prognosis in this case is fair.
PLAN
REGIONAL TREATMENT
==>Manipulation to identified restrictions and limitations in the targeted areas.
==>Deep tissue/trigger point therapy to targeted areas.
==>Lumbar traction per protocols for up to 10 minutes or to the limits of patient tolerance.
TARGETED TREATMENT AREAS: lower thoracic and upper lumbar region, lower lumbar and sacral region
and left sacroiliac region.
ATTENDED E-STIM
Attended pulsed electrical stimulation was applied for 10 minutes over her lower lumbar and sacral region and
left sacroiliac region.
SPINAL DECOMPRESSION THERAPY
Kennedy Neural Flex spinal decompression traction-based treatment with patient positioning based upon the
diagnosis and direction of the HNP or nerve compression was performed for 12 minutes @ ______lbs. per
protocol for nerve compression signs targeting her lower lumbar and sacral region.
THERAPEUTIC EXERCISE
Therapeutic exercise was performed to target her muscles of the left lumbar area and left gluteal region.
Iris Stegmaier
(DOB : Jan 06, 1935)
Page 3
Dec 19, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 19, 2016
RECOMMEND HOME APPLICATION OF MOIST HEAT
Home moist heating pad supplied today. Moist heat, such as hot baths, steamed towels or moist heating
packs can aid in the heat’s penetration into the muscles, and some people feel that moist heat provides better
pain relief. The most effective heat therapy products are the ones that can maintain their heat at the proper
temperature. "Warm" is the proper temperature. The desired effect is for the heat to penetrate down into the
muscles. Simply increasing the temperature of the skin will do little to decrease discomfort. Moist heat should
be applied from 15-20 minutes every hour as needed over her lower lumbar and sacral region and left
sacroiliac region.
TREATMENT PLAN
Iris's chiropractic treatment recommendations are as follows:
Adjustments to her key joint dysfunctions that are involved in her described complaints.
Modalities to improve soft tissue healing and maximize pain control, such as electrical stimulation, and
traction.
Strengthening and/or stretching exercises to improve her overall muscle balance, strength, and coordination.
Patient education to improve her posture and motor control, as well as possibly reduce her anxiety related to
her described functional limitations.
Other treatments such as massage therapy, heat and cold application, and education on ergonomics and
nutrition to maximize healing.
GOALS OF CARE
Decrease her 0-10 reported pain level to a 5 within the first 8 visits and to a 3 within the next 8 visits in
regards to her complaints.
Short-term goal of restoring her normal joint function and muscle balance.
Long-term goals include restoring her functional independence and tolerance to her normal activities of daily
living.
I will see Iris again on Tuesday.
This is an electronically verified report by Dr. David A. Bohn, D. C. ,
CA Therapy Completed As Ordered: ______ Front Desk CA: ______ Visit Number: _____ /_____
Iris Stegmaier
(DOB : Jan 06, 1935)
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Dec 19, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 20, 2016
SUBJECTIVE
Iris feels that her treatment is helping her condition. She says that her lower back pain that radiates into left
hip is feeling much better.
OBJECTIVE
She is feeling much better and is showing improvement in findings since last visit.
P. A. R. T. EVALUATION - (Pain/Tenderness, Asymmetry/Misalignment,Range of Motion Abnormality,
Tissue/Tone)
MISALIGNMENT/ASYMMETRY - Misaligned vertebrae with associated segmental dysfunction including
asymmetry, tenderness, and hypertonicity noted at L4, L5 and sacrum.
TISSUE AND TONE - Visible tissue changes including, hypertonicity, spasm and inflammation was observed
today over her muscles of the left lumbar area and muscles of the right lumbar area.
PAIN WITH PALPATION - Iris reported pain with palpation over her lower thoracic and upper lumbar region,
lower lumbar and sacral region, right sacroiliac region and left sacroiliac region.
ASSESSMENT
Diagnosis remains unchanged, Iris has improved since last visit. Care will continue as ordered.
PLAN
REGIONAL TREATMENT
==>Manipulation to identified restrictions and limitations in the targeted areas.
==>Deep tissue/trigger point therapy to targeted areas.
==>Lumbar traction per protocols for up to 10 minutes or to the limits of patient tolerance.
TARGETED TREATMENT AREAS: lower lumbar and sacral region, left sacroiliac region and right sacroiliac
region.
ATTENDED E-STIM
Attended pulsed electrical stimulation was applied for 10 minutes over her lower lumbar and sacral region.
SPINAL DECOMPRESSION THERAPY
Kennedy Neural Flex spinal decompression traction-based treatment with patient positioning based upon the
diagnosis and direction of the HNP or nerve compression was performed for 12 minutes @ ______lbs. per
protocol for nerve compression signs targeting her lower lumbar and sacral region.
I will see Iris again on Wednesday.
This is an electronically verified report by Dr. David A. Bohn, D. C. ,
CA Therapy Completed As Ordered: ______ Front Desk CA: ______ Visit Number: _____ /_____
Iris Stegmaier
(DOB : Jan 06, 1935)
Page 5
Dec 20, 2016
Iris Stegmaier
Iris Stegmaier
(DOB : Jan 06, 1935)
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 20, 2016
Page 6
Dec 20, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 21, 2016
SUBJECTIVE
Iris has been bothered less by her symptoms and presents today to continue with care.
OBJECTIVE
Iris show slight objective improvement since her last visit.
ASSESSMENT
Iris has progressed significantly since the last visit and I will continue with the current care so long as she
responds as expected. The current diagnosis is unchanged.
P. A. R. T. EVALUATION - (Pain/Tenderness, Asymmetry/Misalignment,Range of Motion Abnormality,
Tissue/Tone)
MISALIGNMENT/ASYMMETRY - Misaligned vertebrae with associated segmental dysfunction including
asymmetry, tenderness, and hypertonicity noted at L4, L5 and coccyx.
TISSUE AND TONE - PALPATED MUSCLE SPASM - Improvement noted with a reduction of the
hypertonicity, spasm, and inflammation while palpating the soft tissue in the area of her lower lumbar and
sacral region.
GENERAL JOINT MOTION ASSESSMENT - I noted an increase or improvement of joint motion in her lower
lumbar and sacral region.
PLAN
REGIONAL TREATMENT
==>Manipulation to identified restrictions and limitations in the targeted areas.
==>Deep tissue/trigger point therapy to targeted areas.
==>Lumbar traction per protocols for up to 10 minutes or to the limits of patient tolerance.
TARGETED TREATMENT AREAS: lower thoracic and upper lumbar region, lower lumbar and sacral region,
right sacroiliac region and left sacroiliac region.
ATTENDED E-STIM
Attended pulsed electrical stimulation was applied for 10 minutes over her lower lumbar and sacral region,
right sacroiliac region and left sacroiliac region.
SPINAL DECOMPRESSION THERAPY
Kennedy Neural Flex spinal decompression traction-based treatment with patient positioning based upon the
diagnosis and direction of the HNP or nerve compression was performed for 12 minutes @ ______lbs. per
protocol for nerve compression signs targeting her
THERAPEUTIC EXERCISE
Therapeutic exercise was performed to target her
I will see Iris again on Thursday.
This is an electronically verified report by Dr. David A. Bohn, D. C. ,
Iris Stegmaier
(DOB : Jan 06, 1935)
Page 7
Dec 21, 2016
Iris Stegmaier
Accent on Health Chiropractic
405 Firemans Ave LaVale, Maryland
21502
Dec 21, 2016
CA Therapy Completed As Ordered: ______ Front Desk CA: ______ Visit Number: _____ /_____
Iris Stegmaier
(DOB : Jan 06, 1935)
Page 8
Dec 21, 2016