MEDICAL HOME CASE REPORT Anthony Bailes, MAcOM, L.Ac. DAOM Candidate 2015 Week 14

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

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

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.

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.

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

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

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

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.

Objective Vitals TCM BP: L Seated 128/68; P: 74; R: 16 Pulse: Tongue: 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.

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.

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.

Acupuncture treatment: 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.

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,

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