Chiropractic Manipulative Therapy Case Summary
DOI: 10/22/2016. Patient is a 48-year-old female residential counselor who sustained injury when she stepped in a pothole and fell to the ground on the side of the road. Per OMNI entry, she was initially diagnosed with right foot sprain, low back contusion and head contusion.
Based on the medical report dated 12/27/16, the patient rates the intensity of pain/symptoms of the right lumbar region at the lumbopelvic area as a 7/10. The patient describes his pain as dull, deep, cramping, sharp with movement, aching and tingling. She reports that the symptoms are aggravated by activities involving standing, lifting, movement, reaching, exercise and household chores. The patient states that some relief is obtained when no movement …show more content…
Patient was diagnosed with segmental and somatic dysfunction of lumbar spine, radiculopathy of the lumbosacral region, other muscle spasm and low back pain.
Of note, chiropractic manipulative therapy for three to four regions was provided for removing structural dysfunctions of the involved joints and associated muscles and secondary neurologic alteration.
On the statement of medical necessity per MG-2 form dated 01/23/17, patient reports reducing pain on a scale of 7/10. Patient still has unremarkable neurological symptoms. Ely’s, Kemp’s, Milgram’s and Nachlas’ are positive and there is an increase in pain in the lumbar region of the spine. Patient has increased active range of motion in the lumbar regions of the spine. All vectors including flexion, extension, bilateral lateral flexion and bilateral rotation increased by 15%. There is reduction of myospasm from +2 to +1 in the lumbar region. Low Back Oswestry score reduced from 60 to 50. Personal care, lifting, pulling, light housework, driving, bending and picking up objects have increased by 20%.
Per verification by the utilization review nurse, the IW already completed 33 chiropractic visits from 10/26/16 to
Based on the medical report dated 12/27/16, the patient rates the intensity of pain/symptoms of the right lumbar region at the lumbopelvic area as a 7/10. The patient describes his pain as dull, deep, cramping, sharp with movement, aching and tingling. She reports that the symptoms are aggravated by activities involving standing, lifting, movement, reaching, exercise and household chores. The patient states that some relief is obtained when no movement …show more content…
Patient was diagnosed with segmental and somatic dysfunction of lumbar spine, radiculopathy of the lumbosacral region, other muscle spasm and low back pain.
Of note, chiropractic manipulative therapy for three to four regions was provided for removing structural dysfunctions of the involved joints and associated muscles and secondary neurologic alteration.
On the statement of medical necessity per MG-2 form dated 01/23/17, patient reports reducing pain on a scale of 7/10. Patient still has unremarkable neurological symptoms. Ely’s, Kemp’s, Milgram’s and Nachlas’ are positive and there is an increase in pain in the lumbar region of the spine. Patient has increased active range of motion in the lumbar regions of the spine. All vectors including flexion, extension, bilateral lateral flexion and bilateral rotation increased by 15%. There is reduction of myospasm from +2 to +1 in the lumbar region. Low Back Oswestry score reduced from 60 to 50. Personal care, lifting, pulling, light housework, driving, bending and picking up objects have increased by 20%.
Per verification by the utilization review nurse, the IW already completed 33 chiropractic visits from 10/26/16 to