MEDICAL HOME CASE REPORT

1. MEDICAL HOMECASE REPORT Anthony Bailes, MAcOM, L.Ac. DAOM Candidate 2015 Week 14

2. Medical Home Team Members AOM - Pamela Gregg-Flax Bio - Allen Cline Health - Thang Bui

3. Reason for visit • 50-year old Hispanic male, well nourished, well developed, AOx3 complains of R hip pain and nonspecific back pain.

4. Subjective • Patient reports motorcycle accident at age 14, resulting in bilateral femur breaks. • A total of 7 breaks between both legs. • Surgical intervention included L acetabular-femur fusion. • Intervention resulted in surgical scar on L leg. • Patient reports limited L knee mobility due to scar tissue.

5. Subjective (cont’d) • Patient also complains of back spasms, • Bilaterally with pain on R>L. • Pain is greater in lumbar region, but radiates up to cervical spine. • Due to predominantly L sided pain, patient compensates stride and is experiencing R hip pain. • Pain is exacerbated by prolonged standing and walking. • Pain is alleviated by physical therapy and acupuncture. • Pain on leg is constant and is localized to area around scar.

6. Medical History • PMH: Type 2 Diabetes, Hypertension • PSH: Post MVA surgery to repair femur breaks and fuse L acetabulum and femur head in 1980. • FMH: Family history of diabetes and hypertension

7. Social History • ETOH: 5-7 drinks/week • TOB: cigarette use, amount not reported • No recreational drug use reported. • Patient is unmarried and lives alone

8. Medications and Supplements • Centrum Silver QD dosage not reported; • Losartan dosage and timing not disclosed; • Metformin dosage and timing not disclosed; • Glucosamine/Chondroitin QD dosage not reported. • NKDA

9. Additional Information • Patient does not require mobility aids. He has previously used chiropractic, but is not currently under care. Patient does not take pain medication. • Patient is insured by Blue Cross Blue Shield of Texas, which covers acupuncture treatments.

10. Objective • Vitals • BP: L Seated 128/68; P: 74; R: 16 • TCM • Pulse: • L: deep, slippery, slightly weak in HT, deep KD Yin; • R: slippery, slightly empty, LU/SP weak, KD Yang deep; • Tongue: • swollen quivering body, slight depression in Lower Jiao, red spots on tip with teeth marks, tongue bifurcated, thick yellow coat, and slight sublingual venous congestion.

11. Physical Exam and ROS • Examination of L leg shows pale keloid scar originating L lumbar and extending to L lateral malleolus, following course along L lateral leg. • ROM exams were not performed due to patent sensitivity. • All other systems unremarkable.

12. Assessment • 50-year old male with generalized bilateral back pain, R hip pain, L leg pain with LROM in L knee. • TCM Differentiation: Qi and Blood stasis in Shaoyang Sinew channels.

13. Plan • Acupuncture treatment: • 1 – Patient in R Lateral Recumbent position • L scar treatment using “Surround Dragon” with 13 needles, medial knee “Surround Dragon” with 3 needles, (L)GB44, ST45, SP1, DU4, UB20, 23, GB20. • 2 – Patient in Prone position • (R) “Surround Dragon” around GB30 with 5 needles, (R) GB32, 34, 40, (R) K3.

14. Plan (cont’d) • Herbs not indicated this visit. • Patient was instructed to “keep moving” and perform light exercise to tolerance, lower sodium intake, sleep on R side when possible, limit TOB and ETOH consumption, avoid prolonged sitting, and to take hot baths to help relieve pain. • Patient was advised to continue weekly acupuncture treatments,

15. Additional Information • CPT Codes: 98710, 98711 • ICD-9 Codes: 719.45, 724.5 • ICD-10 Codes: M25.551, M54.5