Blackhorse Posted Tue 02nd of January, 2018 14:32:38 PM
LUMBAR SPINE: Lumbar alignment is unremarkable to visual inspection with no asymmetries in sagittal or coronal plane. Full range of motion is noted with flexion and extension. No masses, step offs or deformities are noted. There is no PSIS, sacroiliac, piriformis or trochanteric tenderness to palpation noted. No midline pain with palpation or percussion noted.
NEUROLOGIC EXAM: CN grossly intact. Gait is nonantalgic with well coordinated movements of all 4 extremities.
UPPER EXTREMITIES: No visible asymmetries or contractions noted. Sensation grossly intact in bilateral upper extremities. Strength is 5/5 in proximal and distal muscle groups including deltoids, biceps triceps wrist flexors, extensors and intrinsic muscles. Reflexes are 2+ and symmetrical. There is symmetrical muscle tone and bulk. Full range of motion WI out crepitus or deformity is noted. No clubbing, cyanosis or edema of the upper extremities is noted. Capillary refill is <2 sec distally w/ palpable pulses. A negative Hoffman and negative elbow and wrist Tinel's sign is noted.
LOWER EXTREMITIES: No visible asymmetries or contractions noted. Sensation grossly intact in bilateral lower extremities. Strength is 5/5 in proximal and distal muscle groups including iliopsoas, quadriceps hamstrings, ankle and toe dorsiflexors and plantarflexor muscles. Reflexes are 2+ and symmetrical. There is symmetrical muscle tone and bulk. Full range of motion w/ out crepitus or deformity is noted. No clubbing, cyanosis or edema of the lower extremities is noted. Capillary refill is <2 sec distally w/ palpable pulses. A negative straight leg raise and femoral stretch test are noted. Movements are well coordinated w/ unremarkable gait. Tight hamstrings are noted bilaterally but her quadriceps were limber.
JOINT STABILITY: The patient's 4 extremities demonstrate no joint laxity. There is no evidence of any subluxation or dislocation. Joint range of motion appears unremarkable. Diagnostic Studies AP and lateral long-standing scoliosis x-rays obtained in our office today show mild spinal asymmetry is any degree left thoracic curvature and a 10° right lumbar curvature with no abnormal vertebra. Because of a cough x-rays, I could not assess the Risser stage.
Spinal asymmetry of double curve pattern of mild severity
I counseled the patient not to crack the joints repetitively as this could cause irritation. REGARDING HER BACK, A FOLLOW-UP ANY YEARS WARRANTED WITH REPEAT LONG STANDING AP SCOLIOSIS X-RAY OF THE
THORACIC AND LUMBAR SPINE. There is no significant progression, no further follow-up is warranted. Her curvature is very mild and falls under the realm of spinal asymmetry versus true scoliosis. This may correct the she reaches skeletal maturity. I counseled her on occasional use of NSAIDs as needed. I counseled her to stretch her hamstrings. All questions were answered. I will see her back in a year. The patient and her mother appreciated the reassurance. She can pursue activities as tolerated.
What is the ICD-10 code for Tight Hamstring?
SuperCoder Answered Wed 03rd of January, 2018 05:05:40 AM
The appropriate ICD-10 code for hamstring tightness is S76.312A.