Symptomatic Care Plan

DOI: 8/5/2015. Patient is a 24-year-old male who has pain to his right shoulder, back of head and right elbow. Per OMNI, he was initially diagnosed with

Based on the medical report dated 08/12/15, the patient continues to report symptomatic and “good” benefit with chiropractic treatment.
He reports that chiropractic treatment positively impacts his ability to perform his activities of daily living (activities of daily living (ADLs), and has resulted in increased positional tolerances during the previous approved treatment period. For example, he previously stated he could only tolerate standing up to 10 minutes; with chiropractic treatment, this is increased to 15 minutes. He wishes to continue chiropractic treatment over other treatment
Dorso-lumbar range of motion (ROM) has improved as follows: flexion was 70 degrees and now it is 80 degrees, extension was 20 degrees and now it is 25 degrees, left lateral flexion was 15 degrees and now it is 20 degrees, right lateral flexion was 15 degrees and now it is 20 degrees, left rotation was 15 degrees and now it is 25 degrees, and right rotation was 20 degrees and now it is 25 degrees. Patient demonstrates increased tolerance to orthopedic examination procedures. For example, Straight Leg Raise on the right was previously positive at 30 degrees and is now positive at 40 degrees. There is decreased muscular hypertonicity as palpated levels of spinal segmental dysfunction.
Based upon these findings, IW is clearly demonstrating functional improvement with additional chiropractic treatment but has not achieved the expected results of chiropractic treatment, and further care is necessary. Chiropractic treatment is recommended at a frequency of 2 times per week for 8