ICD-10 Academic Testing Chiropractic DESTINATION Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association

Transcription

1 ICD-10 Academic Testing Chiropractic DESTINATION Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association

2 Chiropractic Scenario #1 Narrative Title: TNH 6 Narrative Desc: Tension Headache Age: 33 Height: 65 BP: N/A Resp-rate: N/A Gender: Female Weight: 145 Pulse: N/A Temp: N/A Chief Complaint: Complains of dull aching headache that goes across the forehead with neck and shoulder tenderness. She said this flared up again after a very hectic work week. Past Med. History: History of tension headaches. No other significant medical history. Medications: Amitriptyline 50 mg daily, Ibuprofen 200 mg every 4 hours. Office Visit Notes: Patient known to me for treatment of chronic tension headaches that have responded well to treatment in the past. Patient states that she has been putting in extra hours at work and has been spending most of those hours working on the computer. She said that the headache pain started about 6 days ago along with tenderness in neck and shoulders. No history of injury to her head or neck. She has no visual disturbances and no complains of nausea or vomiting. She did state that she has had no appetite lately. She stopped taking the Amitriptyline 3 weeks ago as she was having problems with dry mouth. She has been taking Ibuprofen 200 mg every 6 hours and that dulls the pain some. Findings indicate tension headache, not intractable. Discussed with patient a treatment plan of CMT, traction and electrical stimulation over the next 3-4 days and then as needed. Patient agrees with the plan. CMT was done to entire cervical area tolerated well, placed in mechanical traction for 30 minutes and electrical stimulation to neck and shoulder areas, 15 min. Patient to ice neck and shoulders for 20 minutes each hour until bedtime. Patient instructed to take Ibuprofen 400 mg every 6-8 hours as needed and to follow-up with attending physician to discuss alternative drugs to treat tension headaches with fewer side effects. Patient to be off work for 3 days. Return to office tomorrow Drugs: Amitriptyline, Ibuprofen G G44.2 M M54.6 R51

3 Chiropractic Scenario #2 Narrative Title: NLC 1 Narrative Description: Non-allopathic lesions Cervical Age: 55 Height: 64 BP: N/A Resp-rate: N/A Gender: Female Weight: 129 Pulse: N/A Temp: N/A Chief Complaint: Patient states she woke up this morning with a stiff neck. She said that she had been working in the garden the day before but didn't recall injuring her neck. Past Med. History: History of auto accident several years ago and suffered a whiplash type injury. Patient is currently taking 200 mg. of Motrin OTC every 4-6 hours for pain. Office Visit Notes: Patient states she woke up this morning with a constant pain in the back of her neck that she rated as a 7/10. She states she was in a rear-end collision several years ago and her only injury was whiplash that was treated with OTC Motrin and Patient denies any recent injury. She was working in the garden yesterday but doesn't recall injuring her neck. Exam reveals tenderness and swelling of tissue of the cervical spine findings suggest segmental and somatic dysfunction of cervical region. She has limited range of motion in her neck. Explained treatment options that include hot/cold packs, massage, CMT and mechanical/manual traction. Patient unable to stay for full treatment today. Adjustment to the cervical area performed. Procedure tolerated well. Patient instructed to apply ice to neck 20 minutes every hour until bedtime. Continue with NSAIDs. Follow up appointment tomorrow for adjustment and treatments. Drugs: Motrin M99.01 M99.81 M54.2 M9901 M95.3 M19.01 M99.11 M79.1

4 Chiropractic Scenario #3 Narrative Title: NLL 1 Narrative Description: Non-allopathic lesions Lumbar Age: 24 Height: 66 BP: N/A Resp-rate: N/A Gender: Female Weight: 130 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of lower back pain that has been getting progressively worse, she unable to stand up straight and had problems sleeping last night due to the pain. Past Med. History: No past medical history. Taking Motrin 400 mg for pain. Office Visit Notes: New Patient here for complaints of pain in her lower back after doing heavy lifting of furniture at home. The pain is in the lumbar area and Patient rates it at 8/10. She says she drives a school bus all day so she spends most of her day sitting. She also has to help special needs children in wheelchairs get on and off the bus which involves bending and some lifting. The pain has been getting progressively worse. Exam findings reveal tenderness in lower back area across the entire lumbar level. Exam and x-rays suggest segmental and somatic dysfunction of the lumbar region. Explained treatment options that include hot/cold packs, CMT and mechanical/manual traction. Patient agrees with plan. Lumbar adjustments completed manual and mechanical stretching and traction was performed Patient could only tolerate 15 min. each. Hot packs applied for 30 minutes. Patient instructed to apply ice to area 20 minutes hourly throughout the day and take Motrin 400 mg every 6 hours for pain as needed. Follow up in 2 days for additional adjustments and treatment. Recommended Patient wear a lumbar back support brace while working and to try to avoid doing any lifting. A work slip was provided to Patient to avoid lifting over pounds for 1 week. Drugs: Motrin M99.03 M54.5 M9903 M S33.5xx M533.5XXA S33.100A

5 Chiropractic Scenario #4 Narrative Title: LES 1 Narrative Description: Late Effect Sprain/Strain Age: 54 Height: 66 BP: N/A Resp-rate: N/A Gender: Male Weight: 170 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain in neck and shoulders and he can hear a cracking of his neck when he moves it. He is also having more frequent headaches. Past Med. History: History of auto accident 6 months ago. Suffered whiplash type injury. No other medical history. Taking NSAIDs for pain. Office Visit Notes: Patient complains of pain in neck. Patient involved in a side impact collision, he said his car was t-boned 6 months ago but did not suffer any serious injury other than sore muscles. He went to the ER at the time and x-ray exams performed. He has not experienced any pain or limitations resulting from the accident since completion of Physical Therapy 4 months ago. Yesterday he turned his head suddenly and experienced severe pain. Today he presents with limited range of motion in his neck, cracking noted with movement. Flexion and extension of the neck causes pain. Exam findings suggest segmental and somatic dysfunctions of cervical region along with sprain of cervical spine ligaments and pain in joint. Explained treatment plan and Patient in agreement. CMT and mechanical and manual traction were applied to the cervical area and hot/cold packs. Adjustment to the cervical area performed. Manual traction techniques used to stretch soft tissue of the neck, followed by hot pack treatments and mechanical traction. Procedures tolerated well. Alternate applications of ice and heat to neck throughout the day. Return tomorrow for adjustment and additional treatment. Drugs: None S13-8xxA S134xxA S13.4xxS M19.01 M54.2 S13.100S S13.4xxA

6 Chiropractic Scenario #5 Narrative Title: BSP-1 Narrative Description: Back Spasm Age: 56 Height: 66 BP: N/A Resp-rate: N/A Gender: Female Weight: 168 Pulse: N/A Temp: N/A Chief Complaint: Patient c/o severe spasms in mid to lower back after working in the garden and bending over to pick up gardening tools. Past Med. History: Chronic back pain. No past medical history. Taking OTC Motrin for pain as needed. Office Visit Notes: Patient returning to the office today because of new injury. Patient states she injured her mid to lower back gardening yesterday and now certain movements cause her back to spasm and is very painful. She rates her pain 6-7/10. She is having trouble sitting and sleeping, but is able to do her ADL s although it is painful. Noted tightness in the lumbosacral area. X-ray and exam findings suggest segmental and somatic dysfunction of the lumbar region and muscle spasms. Spinal adjustment to the L4/L5 S1 region were done as Patient states that is where most of her pain is. Manual traction techniques used to stretch soft tissue of the back for 30 min. followed by hot pack treatments and mechanical traction to back. Recommend getting a prescription from her primary care physician for Valium to help alleviate muscle spasms and possibly a higher dose of Motrin. Continue with Motrin for pain and apply ice to lower back 20 min hourly throughout the day. Return in 2 days for additional adjustment and treatment. Drugs: Valium, Motrin M M99.03 M54.5 M S33.5xxa M62.40 M6240 M62.838

7 Chiropractic Scenario #6 Narrative Title: DCV 1 Narrative Description: Dislocation 1st cervical vertebra Age: 61 Height: 64 BP: N/A Resp-rate: N/A Gender: Female Weight: 129 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain in back of neck after riding the rollercoaster at an amusement park with her grandchildren 3 days ago. Past Med. History: No past medical history. Taking Motrin OTC for pain. Office Visit Notes: New patient Patient states she injured her neck while riding a rollercoaster 3 days ago. She reports her pain as being 5/10 and increases when she turns her head or bends forward. X-ray exam reveals a subluxation of the 1st cervical vertebra and no fracture. She has limited range of motion in her neck. Explained treatment options that include hot/cold packs, massage, CMT and mechanical/manual traction. Adjustment to the cervical area performed. Manual traction techniques used to stretch the neck, area massaged and hot pack treatments applied for 30 minutes. Procedures tolerated well. Continue with Motrin as needed. Apply ice to neck 20 minutes every hour until bedtime. Follow up appointment tomorrow for adjustment and treatments. Drugs: Motrin S13.101S M99.01 M54.2 S13.4XXA S13.101A S13.111A S13.11A S M19.01

8 Chiropractic Scenario #7 Narrative Title: DMV-1 Narrative Description: Dislocation multiple cervical vertebra Age: 58 Height: 62 BP: N/A Resp-rate: N/A Gender: Female Weight: 128 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain in neck following an auto accident last week. Past Med. History: Recent auto-accident, 6 days ago. Was hit from behind and suffered whiplash type injury. ER evaluation at that time did not reveal any fractures or serious injury. Prescribed Tylenol #3, 30 mg. 4-6 hours as needed for severe pain and Motrin 800 mg. every 6 8 hours as needed for mild pain. Office Visit Notes: New patient complains of pain in neck that was the result of a low impact rear-end collision. She has limited range of motion in her neck, but is able to perform ADLs. Patient rates pain as a 7/10. X-ray evaluation done in ER did not reveal any fractures based on copy of report dated 6 days ago. The report does show multiple areas of dislocation. Explained a treatment option that includes massage, CMT and mechanical and manual traction and hot/cold packs. Adjustment to the cervical area performed. Manual traction techniques used to stretch soft tissue of the neck, followed by hot pack treatments and mechanical traction. Procedures tolerated well. Continue with Tylenol #3 and Motrin as prescribed for pain and apply ice to neck for 20 min hourly throughout the day. Return tomorrow for adjustment and additional treatment. Drugs: Tylenol #3, Motrin S13.101S S13.101A S13.4XXA S13.11A M19.01 M54.2

9 Chiropractic Scenario #8 Narrative Title: DLV 1 Narrative Description: Dislocation lumbar vertebra Age: 43 Height: 69 BP: N/A Resp-rate: N/A Gender: Male Weight: 170 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of lower back pain after working on his car last week. Past Med. History: Auto accident 5 years ago with history of fractured L1, treated surgically. History of degenerative disc disease, chronic back pain. Taking OTC Motrin as needed and capsaicin topical lotion 4 times/day for pain. Office Visit Notes: Patient here for follow-up treatment for dislocation of lumbar vertebra that was incurred after working on his car 1 week ago Patient has had ongoing problems with lower back pain since being involved in an auto accident 5 years ago. Patient still has pain with movement, but he notes that he feels improvement with therapy. Adjustment to lumbar region in the L4-L5/S1 area and manual traction applied for 30 minutes Patient to continue with current medications and to apply ice to area 20 minutes hourly throughout the day. Patient cautioned not to use heating pad following application of capsaicin cream and to avoid any heavy lifting. Follow up in 2 days for additional adjustments and treatment. Drugs: Motrin S33.141S M99.03 G89.29 M51.36 M S33.101A M99.13 M54.5 S33.141D S32.9xxS

10 Chiropractic Scenario #9 Narrative Title: BNT 1 Narrative Description: Brachial Neuritis Age: 19 Height: 65 BP: N/A Resp-rate: N/A Gender: Female Weight: 130 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of arm pain and having a sensation of "pins and needles" in her right arm, pain in neck and right shoulder and having trouble sleeping. Past Med. History: Diagnosed with brachial radiculitis due to complications of arthritis. Patient takes Celebrex 200 mg. 2 /day and recently started Flexeril 5 mg. 3/day. Office Visit Notes: Patient complains of numbness and tingling in her right arm and pain in her neck when flexing and extending. She has recently been treated by her attending physician for brachial radiculitis. Her attending recommended chiropractic care in addition to her current treatment plan. She has limited range of motion in her neck. History, physical exam and x-ray findings suggest cervical disc disorder with radiculopathy, occipito-atlanto-axial region. Explained treatment options that include massage, CMT, electrical stimulation and mechanical and manual traction and hot/cold packs. Patient in agreement with the plan. Adjustment to the cervical area performed. Manual traction techniques used to stretch soft tissue of the right side neck and right shoulder. Also applied electrical stimulation for 15 minutes to the right neck and shoulder area, followed by hot pack treatments and mechanical traction. Procedures tolerated well. Continue with current medications. Return in 2 days for adjustment and additional treatment. Drugs: Celebrex, Flexeril M54.12 M50.12 M54.11 M50.21 M54.13

11 11