DOI: 8/28/2014. The patient is a 55-year-old male laborer who sustained injury when he was involved in a vehicle collision while moving his vehicle from one area of parking lot to another. Per OMNI, he was initially diagnosed with sprain at the back, neck, shoulder, bilateral legs and ankle.
Based on the acupuncture progress report dated 03/22/16, the patient presents for his 6/8 visit for his cervical and lumbar spine. He reports excellent pain relief with treatment, more tolerable pain levels for several days and that his whole back feels more relaxed. At present, his neck is bothering him more than his low back. He also complains of a “nerve type of pain” along the posterior knee. He is eager for additional treatment. He notes that pain medications, acupuncture, rest, heat and ice all help. Patient reports his pain as 7/10.
On examination of the cervical …show more content…
On palpation, paravertebral muscles, spasm and tenderness is noted on both sides. Spinous process tenderness is noted on L4 and L5.
Diagnoses include chronic pain syndrome, lumbar radiculopathy, cervicalgia, low back pain and ankle and foot synovitis/tenosynovitis.
IW will benefit from 8 additional sessions of acupuncture for his cervical and lumbar spine. Patient has completed 6 sessions with good benefit. Patient reports having fewer flare-ups, improvement with pain and able to engage better on his home exercise program.
It is anticipated that acupuncture sessions as part of comprehensive pain management treatment plan, will contribute to patient’s recovery increasing his possibilities to have a positive short-term effect on pain interference and long-term effect on functional restoration.
Current request is for 8 Acupuncture Therapy Visits for the Cervical Spine and Lumbar Spine between 4/13/2016 and
Based on the acupuncture progress report dated 03/22/16, the patient presents for his 6/8 visit for his cervical and lumbar spine. He reports excellent pain relief with treatment, more tolerable pain levels for several days and that his whole back feels more relaxed. At present, his neck is bothering him more than his low back. He also complains of a “nerve type of pain” along the posterior knee. He is eager for additional treatment. He notes that pain medications, acupuncture, rest, heat and ice all help. Patient reports his pain as 7/10.
On examination of the cervical …show more content…
On palpation, paravertebral muscles, spasm and tenderness is noted on both sides. Spinous process tenderness is noted on L4 and L5.
Diagnoses include chronic pain syndrome, lumbar radiculopathy, cervicalgia, low back pain and ankle and foot synovitis/tenosynovitis.
IW will benefit from 8 additional sessions of acupuncture for his cervical and lumbar spine. Patient has completed 6 sessions with good benefit. Patient reports having fewer flare-ups, improvement with pain and able to engage better on his home exercise program.
It is anticipated that acupuncture sessions as part of comprehensive pain management treatment plan, will contribute to patient’s recovery increasing his possibilities to have a positive short-term effect on pain interference and long-term effect on functional restoration.
Current request is for 8 Acupuncture Therapy Visits for the Cervical Spine and Lumbar Spine between 4/13/2016 and