ONMM CONSULT

ONMM CONSULT – INITIAL VISIT

HPI: [patient name] is a [age] year old [gender] new patient to me and the Osteopathic Manipulative Medicine service who is referred by Dr. Hovey for my initial evaluation of [chief complaint].

F/U VISIT:
HPI: [patient name] is a [age] year old [gender] here for f/u eval of [chief complaint].  He/She was last seen on [date] for [chief complaint] for which he/she was treated with OMT (and other treatments if performed) which was tolerated well. (describe treatment effect as they left the office, that day, the next day and the time since that appointment)  

<Complete HPI>

The PMH, PSH, Family Hx, Social Hx, Meds and Allergies have been reviewed and updated in the chart.

Review of systems:

General: denies fever, bleeding, recent injury or accident
HEENT: denies recent change in vision, sinus congestion
Resp: denies SOB, cough
CV: denies CP at rest, palpitation
GI: denies vomiting, nausea, diarrhea, heartburn
GU: denies painful urination, blood in urine
Derm: denies rash, skin lesion
Neuro: denies numbness, tingling, weakness, loss of bowel or bladder control
MSK: denies red or hot joints, admits pain in the

<For LBP Complaint: Denies radiculopathy, lower extremity weakness, saddle anesthesia, foot drop, fecal incontinence, urinary retention>

PHYSICAL EXAM:

Vitals: [vitals]

GENERAL APPEARANCE: well developed, well nourished, in no acute distress

HEAD: normocephalic, atraumatic.

EYES: pupils equal, round, sclera non-icteric, no discharge

HEENT: wearing a mask <or the exam as completed>

NECK: Full active and passive ROM, supple

LYMPH NODES: no cervical adenopathy, no supraclavicular adenopathy, no epitrochlear adenopathy

LUNGS: symmetrical chest excursion on inspection, no conversational dyspnea

HEART: regular rate and rhythm, no murmurs, rubs or gallops noted

ABDOMEN: soft, non-tender, non-distended

PERIPHERAL PULSES: 2+ radial, 2+ posterior tibial/Pedal

PSYCH: alert, oriented x3, cooperative with exam

SKIN: normal, good turgor, no rashes in exposed areas, warm and dry

NEURO:

MSK:
{joint exam templates here}
{somatic dysfunction finding options here}

Assessment: { any medical problem on their problem list } { any or all m99 code}

Impression/Plan: [patient name] is a [age] year old [gender] seen today for evaluation of [cc]

1. I reviewed previous notes and imaging.
2.  Education: discussed exam findings and diagnosis to include possible etiology.
3.  After evaluation and review of the exam findings/diagnosis today.  I feel that OMT would likely benefit the patient based on the above history and physical exam and is indicated for signs and symptoms including local and remote somatic dysfunction findings and related neurokinetic, lymphatic, fascial &/or arteriovenous body connections. We discussed risks, benefits, and alternatives to OMT.  Verbal informed consent was obtained to proceed with OMT applied to the above SD Diagnosis.  MET,  MFR, BLT.  OMT tolerated well with objective and subjective improvement noted. There were no adverse effects from the OMT prior to leaving the office.  Discussed post OMT recommendations including hydration, relative rest, ice or heat and over the counter analgesics.  
4. Continue current level of activity.  No restrictions or HEP recommended today.  OK for ice, heat, OTC analgesics PRN if he has some post treatment soreness or if presenting discomfort returns prior to next visit.
5. Continue all current care provided by PCP or other physician as instructed unless instructed to change by that physician or another who is addressing any other problems not considered today.
6. Will follow-up with the patient in 2-4 weeks. Advised patient to monitor post treatment response for review at next visit.  
He/She voices understanding and agreement with this plan.

Seen with OMS3 XXXXX and XXXXXX

Time in XXXX, Time out XXXX


Other standard comments:

In the review of his PMH he did indicate that he is not vaccinated against COVID 19.  I recommend he receive this vaccine, but respect his preference not to.  If he chooses not to be immunized, he needs to follow the CDC guidance for masking, hand washing and social distancing.  He understands and appreciates the information.


OMT 6 regions - performed to noted somatic dysfunctions in objective. Oral consent obtained. Reviewed benefits & potential side effects. Indicated for signs and symptoms including local and remote somatic dysfunction findings and related neurokinetic, lymphatic, fascial &/or arteriovenous body connections. OMT types used: Articulatory, MFR, MET, BLT and CS. Tolerated well. Improved segmental mobility post-treatment in noted regions of somatic dysfunction.
2. OTC Tylenol, NSAIDs, ice or heat are reasonable for episodes of pain.
3.  Discussed starting a core strength program, working out with a personal trainer with focus on endurance or if sx do not improve with OMT and HEP, then formal PT should be considered.
4. F/u 1-2 weeks PRN