Form Pr-2 - Primary Treating Physician'S Progress Report (Pr-2) Sample Page 2
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8RE: CARTER, LINDA J.
DOE: January 12, 2015
Page 2
Neurological examination reveals intact mental status, intact cranial nerves II – XII, and intact coordination. Biceps reflex is diminished
on the left with a grade of 1+. Sensory examination reveals diminished sensation over the dorsum of the hand, and sensation testing
with a pinwheel is slightly abnormal over the lumbar spine.
Diagnoses:
1.
Left shoulder impingement.
ICD-9
726.2
2.
Thoracic outlet syndrome.
ICD-9
353.0
3.
Carpal tunnel syndrome.
ICD-9
354.0
4.
Brachial plexus lesion.
ICD-9
353.0
5.
Cervical disc herniation.
ICD-9
722.0
6.
Status post left-sided L3-L4, L4-L5 laminectomy/microdiscectomy surgery, 05/04/13.
ICD-9
V45.89
7.
L3-L4, L4-L5 and L5-S1 herniated nucleus pulposus and instability.
ICD-9
722.10; 724.6
8.
L5-S1 degenerative disc disease.
ICD-9
722.52
9.
Fibromyalgia
ICD-9
729.1
Treatment Plan:
The patient meets all the requirements in the guidelines to warrant:
Eight visits of aquatic therapy to the patient’s cervical and lumbar spine at a frequency of two times a week for four weeks
•
MRI scan of the cervical spine
•
MRI scan of the lumbar spine
•
1. Authorization for eight visits of aquatic therapy to the patient’s cervical spine and lumbar spine at a frequency of two times a week
for four weeks.
Pursuant to the guideline California Code of Regulations, Title 8, Article 5.5.2 Medical Treatment Utilization Schedule (MTUS), Section
9792.20 et seq., Effective July 18, 2009, § 9792.24.2 Chronic Pain Medical Treatment Guidelines, Subdivision (a), Part 2 - Pain
Interventions and Treatments, page 98, under Physical Medicine
, “Active therapy is based on the philosophy that therapeutic exercise
and/or activity are beneficial for restoring flexibility, strength, endurance, function, range of motion, and can alleviate discomfort.”
Also,
as per California Code of Regulations, Title 8, Article 5.5.2 Medical Treatment Utilization Schedule (MTUS), Section 9792.20 et seq.,
Effective July 18, 2009, § 9792.24.2 Chronic Pain Medical Treatment Guidelines, Subdivision (a), Part 2 - Pain Interventions and
Treatments, page 47, under Exercise,
“Physical therapy in warm-water has been effective and highly recommended in persons with
fibromyalgia.”
Furthermore, as per California Code of Regulations, Title 8, Article 5.5.2 Medical Treatment Utilization Schedule
(MTUS), Section 9792.20 et seq., Effective July 18, 2009, § 9792.24.2 Chronic Pain Medical Treatment Guidelines, Subdivision (a), Part 2
“Recommended as an optional form of exercise therapy, where
- Pain Interventions and Treatments, page 22, under Aquatic therapy,
available, as an alternative to land-based physical therapy. Aquatic therapy (including swimming) can minimize the effects of gravity, so
it is specifically recommended where reduced weight bearing is desirable, for example extreme obesity.” Also on the same page, “Water
exercise improved some components of health-related quality of life, balance, and stair climbing in females with fibromyalgia. … (Tomas-
Carus, 2007).”
The patient meets the criteria in the guidelines:
Based on the following clinical evidence provided in
the records:
PHYSICAL THERAPY
1. Active therapy is based on the philosophy that therapeutic
The patient has completed 15 sessions of combined pool and
exercise and/or activity are beneficial for restoring flexibility,
land therapy with improvement in range of motion, decrease
strength, endurance, function, range of motion, and can
pain, and is able to do more daily activities and work. [PR-2
alleviate discomfort.
dated 12/05/14/]
EXERCISE
1. Physical therapy in warm-water has been effective and
The patient is diagnosed with fibromyalgia and currently has
highly recommended in persons with fibromyalgia.
the following symptoms: (1) Constant severe neck pain that
she rates as 8/10 on a pain scale; (2) Constant severe low
back pain that she rates as 8/10 on a pain scale; (3) Review
of systems reveals weakness and fatigue; (4) Tenderness in
the left trapezius and paracervical muscles; and (5)
Tenderness in the paralumbar muscles.
The above
mentioned symptoms in my experience and expertise as an
orthopedic surgeon, together with the applicable guidelines,
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