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Osteopathic Manipulation Treatment Transcription Sample

CHIEF COMPLAINT:  Left groin and hip pain, left lower leg pain, left ankle and foot pain.

HISTORY OF PRESENT ILLNESS:  The patient returns in followup today having last been seen for initial evaluation 3 weeks ago at the consultative request of Dr. John Doe. At that time, the patient was complaining of the aforementioned complaints. Today, the patient’s biggest complaint is the left groin and hip, which seems to be getting worse. The patient did have an MRI of the hip and the pelvis this morning, which is not yet available to be reviewed. The other pains that the patient is having seem to be less problematic in that the groin is really overshadowing everything. The patient describes a worsening of the catching, sharp, throbbing sensation in the groin, which is present intermittently, but daily throughout the day. The average pain intensity has increased. It is now 9/10 on VNS on average.

It is still worse when the patient stands and walks and better when the patient sits. Previous x-rays have been normal, of the hip. MRI of the back was significant only for a diffuse bulge at L4-L5 and a central disk protrusion at L5-S1 with moderate to severe tricompartmental stenosis at L4-L5. The patient has no interval change in bowel or bladder. There is no new numbness or weakness in the legs. The patient still has persistent sleep problems and has no constitutional symptom or increased Valsalva. As stated above, MRI of the hip and the pelvis was performed this morning and the results are pending. I have told the patient that I will call with the results tomorrow.

I have sent the patient to Podiatry for orthotics for the left foot given the previous left ankle and foot fracture and that appointment is pending. The patient did try a Lidoderm patch; however, did not feel that it was penetrating deep enough. The patient does have pain in the left anterolateral thigh consistent with meralgia paresthetica.

REVIEW OF SYSTEMS:  Only positive for poor sleep and this is caused by the pain.

FUNCTIONAL HISTORY:  Oswestry disability questionnaire did reveal that the pain is fairly severe at the moment, especially with weightbearing. Pain prevents the patient from lifting heavy weights but can manage to lift light-to-medium weights if conveniently positioned. Pain prevents the patient from walking more than 500 meters. Can sit in a chair as long as the patient wants. Pain prevents the patient from standing more than 15 minutes. Sleep is occasionally disturbed by pain. Social life is restricted. Travel is limited.

PHYSICAL EXAMINATION:  The patient is awake, alert and oriented, pleasant, cooperative. The patient has a blood pressure of 128/72, pulse 74, respirations 22. Current pain score is 9/10 on VNS. No pain behaviors. Mood and affect appropriate and euthymic today. On exam, the patient has intact motor power of the muscles of the bilateral extremities with intact sensation. Seated straight leg raise negative for leg pain. Femoral stretch was positive for anterior thigh pain. The patient had a very significant antalgic gait. Continued to have a cephalad left ASIS with a positive left seated flexion test. The patient has significant tightening in the thoracolumbar fascia. Had tightness in the hamstrings. Had focal tenderness over the lateral trochanter as well as over the lateral knee and the lateral lower leg.

The patient underwent osteopathic manipulative medicine treatment including myofascial release, muscle energy, and counterstrain treatment in the back, pelvis and lower extremity regions, including the sacrum. The patient had multiple tender points in the left anterolateral thigh, left lateral knee and the left lateral leg, as well as the dorsum of the foot over the fifth metatarsal especially. These were all treated successfully with counter-straining. The patient had some improvement in mobility afterwards. The patient tolerated OMT well and wishes to proceed again with another treatment.

ASSESSMENT:  The patient is a pleasant (XX)-year-old with multiple pain complaints, including left groin and hip, left anterior thigh, left lower leg and foot. Symptoms are verified and consistent with:
1.  Lumbar spondylosis.
2.  Lumbar spinal stenosis with mild neurogenic claudication.
3.  Left hip and groin pain with MRI of pelvis and hip pending.
4.  Left trochanteric bursitis.
5.  Left sacroiliac joint dysfunction.
6.  Status post left fifth metatarsal fracture and fibular fracture with persistent pain.
7.  Pelvic obliquity with innominate dysfunction.
8.  Somatic dysfunction lumbar, pelvic, sacral, lower extremity regions.
9.  Relative physical deconditioning and functional decline.

1.  At this point, we are awaiting the results of the MRI. We have told the patient we will call tomorrow with results and we will go from there.
2.  We are going to prescribe Zanaflex for help with sleep at night, which might also help with muscle spasm.
3.  The patient is going to follow up with me for repeat OMT.
4.  The patient is going to continue with the PT program. We have specifically outlined areas for the patient to concentrate on. The patient is going to relay that to the therapist.
5.  The patient has an outstanding appointment with Orthotics.