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[Solved]: We saw the patient today for an initial evaluation…

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We saw the patient today for an initial evaluation with the following results: SUBJECTIVE FINDINGS: This patient is a 55-year-old white female with pain in her lumbosacral spine, extending into her buttocks bilaterally. She describes the pain as being sharp and sometimes intense. She states it diminishes to an achy feeling. She rates its intensity at 10/10 at its worst. Normally, she states it is 6–7/10. She describes the pain as being ever-present, varying in intensity, increasing with activities and decreasing with rest. She is using pain medications currently and is able to sleep through the night. She presents for an evaluation of range of motion and to recommend potential treatment. HISTORY: This patient initially injured her back by catching a falling TV. She had immediate pain, it was disabling. The pain was resolved with occasional recurrence. She sought intervention last year from doctors, who diagnosed degenerative disc disease and arthritis. She had a course of physical therapy with some resolution, but recurrence of pain occurred in September secondary to bending over while washing her hands. She was referred here. OBJECTIVE FINDINGS: Observation: This patient appears as a normally developed white female of stated age. She reports moving with forward flexed posture and an occasional antalgic gait on the right when the pain is increasing. She currently postures and moves normally. Palpation: Positive over L4 and L5 and paravertebral muscles at that same level. Range of motion: Forward flexion 35 degrees with pain at the end of range. Right side bending 30 degrees with pain at the end of range. Left side bending 35 degrees. Extension 0 degree with pain at the end of range. RESISTED MOTION: Positive in all directions. DTRs: Hyperreflexive bilaterally. LASÈGUE’S SIGN: Positive at 25 degrees bilaterally. CRAM TEST: Positive at 25 degrees bilaterally. CERVICAL RANGE OF MOTION: 1. Right side bending: Within normal limits, painful. 2. Left side bending: Within normal limits. 3. Forward flexion: 45 degrees with pain at the end of range. 4. Extension: Within normal limits. RADICULOPATHY: Positive with pain down the left arm and occasional tingling and numbness. TREATMENT PLAN: We would like to see the patient three times per week to initiate exercises and modalities to decrease pain and increase range of motion and function. GOALS: The purpose of physical therapy intervention is to: 1. Increase range of motion to normal limits. 2. Decrease pain to zero. 3. Increase strength and function to normal. The ICD-10-PCS Code is: _________.

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