12/8/23, 8:48 AM

MRN:

Office Visit 4/28/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Peachtree Spine Physicians Primary diagnosis: Cervicalgia
Stonecrest Reason for Visit: Headache Neck Pain Back Pain Thoracic Pain

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

PEACHTREE SPINE
PSP AND SPORTS PHYSICIANS

PEACHTREE SPINE PHYSICIANS STONECREST

8225 MALLPARKWAY,SUITE 250
LITHONIAGA 30038-7103
404-843-3323

Subjective:

Subjective
Patient ID: is a 65 y.o. female.

Chief Complaint:
Chief Complaint
Patient presents with
Headache
6/10, intermittent
Neck Pain
7/10
Back Pain
7/10
Thoracic Pain
7/10, intemittent

HPI
The patient complains of neck, mid-back, and low-back pain. Date of Injury:04/03/2023. The pain is
occasional and described as aching. The symptoms are aggravated by laying and sitting and are relieved
by changing positions. Patient reports no associated symptoms in these areas. Patient has not visited
another provider for this problem to date and has treated this problem with medication and chiropractic
care. For this problem, the patient has had no imaging to date.

Review of Systems
Constitutional: Negative for weight loss.
HENT: Negative for tinnitus.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for constipation and nausea.
Genitourinary:
No Incontinence
Musculoskeletal: Positive for back pain and neck pain.
Skin: Negative for rash.
Neurological: Positive for headaches. Negative for dizziness, seizures, loss of consciousness and
weakness.
Psychiatric/Behavioral: The patient has insomnia.

History reviewed. No pertinent past medical history.

Past Surgical History:
Printed by Crissandra Webb at 12/8/2023 8:48 AM 1/23
12/8/23, 8:48 AM

Procedure Laterality Date

APPENDECTOMY
URETER SURGERY

Family History
Problem Relation Age of Onset
Hyperlipidemia Other
Heartdisease Other
Cancer Other
Social History

Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Substance Use Topics
Alcohol use: Never

No Known Allergies
Current Outpatient Medications
Medication Sig Dispense Refill
capsaicin-methyl sal-menthol Apply 10 mLs 1 each 0
(NEW TEROCIN) 0.025-25-10 topicallyas needed.
% Lotn
naproxen sodium (ALEVE)220 Take 220 mg by
MG tablet mouth in the
morning and 220 mg
before bedtime.

No current facility-administered medications for this visit.

Objective:

PHYSICAL EXAM
Gen: No acute distress, cooperative and pleasant
HEENT: Normocephalic, atraumatic
CV: Warm distal extremities, no pallor
Pulm: Non-labored breathing on room air, speaking in full sentences
Neuro:
-Cranial nerves II-XIIintact
-Strength: 5/5 throughout bilateral upper and lower extremities
-Sensation: Intactthroughout bilateral upper and lower extremities
-Reflexes:
-DTRs: 2+ and symmetric throughout bilateral upper and lower extremities
-UMNsigns: Negative Hoffman's reflex bilaterally; Negative for ankle myoclonus bilaterally

CERVICAL SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in extension > flexion
-Limited in lateral rotation to both the LEFT and RIGHT
Tenderness to palpation:
-Midline
-RIGHT > LEFT cervical paraspinals
-Bilateral upper trapezius muscles
THORACIC SPINE
Inspection:
Printed by Crissandra Webb at 12/8/2023 8:48 AM 2/23
12/8/23, 8:48 AM

-No surgical scars, swelling, or bruising

Tenderness to palpation:
-Midline (Upper)
-RIGHT periscapular

LUMBAR SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in extension > flexion
Tenderness to palpation:
-Midline
-Bilateral lumbar paraspinals

Orders Placed This Encounter

X-raythoracic spine 4 or more views
Standing Status: Future
Number of Occurrences: 1
Standing Expiration Date: 4/28/2024
X-ray cervical spine complete with oblique flexion and extension
Standing Status: Future
Number of Occurrences: 1
Standing Expiration Date: 4/28/2024
X-ray lumbar spine complete with bending 6 or more views
Standing Status: Future
Number of Occurrences: 1
Standing Expiration Date: 4/28/2024
capsaicin-methyl sal-menthol (NEW TEROCIN) 0.025-25-10 % Lotn
Sig: Apply 10 mLs topically as needed.
Dispense: 1 each
Refill: 0

ICD-10-
CM
1. Cervicalgia M54.2 X-raycervical spine complete with
oblique flexion and extension
capsaicin-methyl sal-menthol (NEW
TEROCIN) 0.025-25-10 % Lotn

2. Pain in thoracic spine M54.6 X-raythoracic spine 4 or more views

capsaicin-methyl sal-menthol (NEW
TEROCIN) 0.025-25-10 % Lotn

3. Lumbar spine pain M54.50 X-ray lumbar spine complete with bending
6 or more views
capsaicin-methyl sal-menthol (NEW
TEROCIN) 0.025-25-10 % Lotn

4. Acute post-traumatic headache, not G44.319 capsaicin-methyl sal-menthol (NEW

intractable TEROCIN) 0.025-25-10 % Lotn

5. Car driver injured in collision with other V43.52X X-ray thoracic spine 4 or more views
type car in traffic accident, initial encounter A
X-ray cervical spine complete with oblique
flexion and extension
X-ray lumbar spine complete with bending
6 or more views
capsaicin-methyl sal-menthol (NEW
TEROCIN) 0.025-25-10 % Lotn
3/23
12/8/23, 8:48 AM

6. Unspecifiedstreet and highwayas the Y92.410 X-raythoracic spine 4 or more views

place of occurrence of the external cause
X-ray cervical spine complete with oblique
flexion and extension
X-ray lumbar spine complete with bending
6 or more views
capsaicin-methyl sal-menthol (NEW
TEROCIN) 0.025-25-10 % Lotn

Assessment & Plan:

Assessment
is a 65-year-old woman who presents for evaluation of injurysustained as a direct result of a
motorvehicle accident that occurred on 4/3/2023. She describes operating her vehicle as a restrained
driverwhen she was rear-ended. The airbags did not deploy. She denies loss of consciousness. Since
the time of the accident, she has been receiving chiropracticcare 3 times a week with Dr.Connelly which
has been helpful.

She complainsof headaches. She states that she had a constant headache untiljust 2 days ago after
which time the headaches seem to have subsided. Cranial nerves II-XIInormal on examination.

She complains of severe neck pain. Active range of motion of the cervical spine is limitedin extension
more than flexion. There is tenderness to palpation along the right greater than left cervical paraspinals.
Strength, sensation, and reflexes are intact and symmetric throughout the upper extremities. Hoffmann's
reflex negative bilaterally. Spurling's test negative bilaterally.

She also complains of severe pain in the thoracic region. There is tenderness to palpation along the
midlineof the upper thoracic spine over the spinous processes. There is also rightperiscapular
tenderness to patient.

Additionally,she complains of severe low back pain. Visual inspection of the low back does not reveal
surgical scars, obvious scoliosis, swelling, or bruising. Active range of motion of the lumbarspine is
limitedin extension more than flexion. There is tenderness palpation along bilateral lumbar paraspinals.
Strength, sensation, and reflexes are intact and symmetric throughout the lower extremities. Straight leg
raise is negative bilaterally.

I have recommended that she continue to use Tylenol as needed for pain. I have also prescribed Terocin
lotion to be used as an additional as needed analgesic. I am also ordering x-rays of the cervical, thoracic,
and lumbarspine in orderto assess forjoint degeneration, as well as to indirectlyassess for potential
intravertebral disc height loss. I will follow-up with her in about 1 week to review the above x-rays, at
which time injection therapy may be considered. Note that patient is extremely claustrophobic and states
that she is unable to undergo any form of MRI imaging including open MRIswith preprocedural sedation.

This Patient care visit occurred during a Public Health Emergency for Coronavirus/Covid-19. Therefore
this visit required additional personnel, time and supplies to maintain facial masking, social distancing,
temperature/symptom screening, and increased sanitation.
Kevin C. Pelletier, MD

Instructions
Printed by Crissandra Webb at 12/8/2023 8:48 AM 4/23
12/8/23, 8:48 AM

After Visit Summary (Printed 4/28/2023)

Communications

Orders Placed
X-raycervical spine complete with oblique flexion and extension (Resulted 5/1/2023)
X-raylumbar spine complete with bending 6 or more views (Resulted 5/1/2023)
X-raythoracic spine 4 or more views (Resulted 5/1/2023)

Medication Changes
As of 4/28/2023 11:46 AM
Refills Start Date End Date
Added: capsaicin-methyl sal-menthol (NEW TEROCIN) 0 4/28/2023
0.025-25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)

Medication List at End of Visit

As of 4/28/2023 11:46 AM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary:Cervicalgia M54.2
Pain in thoracic spine M54.6
Lumbarspine pain M54.50
Acute post-traumatic headache, not intractable G44.319
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecifiedstreet and highway as the place of occurrence of the external cause Y92.410

MRN:909773300

SEB X-RAY 5/1/2023 Primary diagnosis: Cervicalgia

Peachtree Spine Physicians Reason for Visit: Referred by Kevin C Pelletier, MD
Decatur Imaging

Communications

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12/8/23, 8:48 AM

Orders Performed
X-ray cervical spine complete with oblique flexion and extension (Resulted 5/1/2023)

Medication Changes
As of 5/1/2023 11:44 AM

None

Medication Listat End of Visit

As of 5/1/2023 11:44 AM
Refills Start Date End Date
capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Cervicalgia M54.2
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecified street and highway as the place of occurrence of the external cause Y92.410

MRN:

SEB X-RAY 5/1/2023 Primary diagnosis: Lumbar spine pain

Peachtree Spine Physicians Reason for Visit: Referred by Kevin C Pelletier, MD
Decatur Imaging

Communications

Orders Performed
X-raylumbar spine complete with bending 6 or more views (Resulted 5/1/2023)

Medication Changes
As of 5/1/2023 11:44 AM

None

Medication Listat End of Visit

As of 5/1/2023 11:44 AM

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12/8/23, 8:48 AM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Lumbar spine pain M54.50
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecifiedstreet and highway as the place of occurrence of the external cause Y92.410

MRN:

SEB X-RAY 5/1/2023 Primary diagnosis: Pain in thoracic spine

Peachtree Spine Physicians Reason for Visit: Referred by Kevin C Pelletier, MD
Decatur Imaging

Instructions
After Visit Summary (Printed 5/1/2023)

Communications

Orders Performed
X-raythoracic spine 4 or more views (Resulted 5/1/2023)

Medication Changes
As of 5/1/2023 11:44 AM

None

Medication List at End of Visit

As of 5/1/2023 11:44 AM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10% Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Pain in thoracic spine M54.6
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Printed by Crissandra Webb at 12/8/2023 8:48 AM 7/23
12/8/23, 8:48 AM

Unspecified street and highway as the place of occurrence of the external cause Y92.410

MRN:

Office Visit 5/5/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Peachtree Spine Physicians Primarydiagnosis: Cervical spondylosis
Stonecrest Reason for Visit: Neck Pain Thoracic Pain Back Pain

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

PSP PEACHTREE
AND SPORTS
SPINE
PHYSICIANS

PEACHTREE SPINE PHYSICIANS STONECREST

8225 MALLPARKWAY,SUITE 250
LITHONIAGA 30038-7103
404-843-3323

Subjective:

Subjective
Patient ID: is a 65 y.o. female.

Chief Complaint:
Chief Complaint
Patient presents with
Neck Pain
7/10
Thoracic Pain
7/10
Back Pain
7/10

HPI
Patient is following up to review her X-Rays. Patient is currently experiencing pain in their neck, mid-back,
and low-back. The pain is continuous and described as dull and aching. The symptoms are aggravated by
laying and sitting. Patient reports no associated symptoms in these areas.

Review of Systems
Constitutional: Negative for weight loss.
HENT: Negative for tinnitus.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for constipation and nausea.
Genitourinary:
No Incontinence
Musculoskeletal: Positive for back pain and neck pain.
Skin: Negative for rash.
Neurological: Positive for headaches. Negative for dizziness, seizures, loss of consciousness and
weakness.
Psychiatric/Behavioral: The patient has insomnia.

History reviewed. No pertinent past medical history.

Past Surgical History:
Procedure Laterality Date
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12/8/23, 8:48 AM

APPENDECTOMY
URETER SURGERY

Family History
Problem Relation Age of Onset
Hyperlipidemia Other
Heart disease Other
Cancer Other
Social History

Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Substance Use Topics
Alcohol use: Never

No Known Allergies
Current Outpatient Medications
Medication Sig Dispense Refill
capsaicin-methyl sal-menthol Apply 10 mLs 1 each 0
(NEW TEROCIN) 0.025-25-10 topicallyas needed.
% Lotn
naproxen sodium (ALEVE)220 Take 220 mg by
MG tablet mouth in the
morning and 220 mg
before bedtime.
No current facility-administered medications for this visit.

Objective:

PHYSICAL EXAM
Gen: No acute distress, cooperative and pleasant
HEENT: Normocephalic, atraumatic
CV: Warm distal extremities, no pallor
Pulm: Non-labored breathing on room air, speaking in full sentences

CERVICAL SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in extension > flexion
-Limited in lateral rotation to both the LEFT and RIGHT
Tenderness to palpation:
-Midline
-RIGHT > LEFT cervical paraspinals
-Bilateral upper trapezius muscles

THORACIC SPINE
Inspection:
-No surgical scars, swelling, or bruising
Tenderness to palpation:
-Midline (Upper)
-RIGHT periscapular

LUMBAR SPINE
Inspection:
-No surgical scars, swelling, or bruising
Printed by Crissandra Webb at 12/8/2023 8:48 AM 9/23
12/8/23, 8:48 AM

Active range of motion:

-Limited in extension > flexion
Tenderness to palpation:
-Midline
-Bilateral lumbar paraspinals

No orders of the defined types were placed in this encounter.

ICD-10-
CM
1. Cervicalspondylosis M47.812

2. Thoracic spondylosis M47.814

3. Lumbarspondylosis M47.816

4. Acute post-traumaticheadache, not G44.319

intractable
5. Numbness and tingling of right lower R20.0
extremity
R20.2

6. Car driver injured in collision with other V43.52X

type car in traffic accident, initial encounter A

7. Unspecified street and highway as the Y92.410

place of occurrence of the external cause

Assessment & Plan:

Assessment
is a 65-year-old woman who presents for follow up for injuriessustained as a direct result of a
motorvehicle accident that occurred on 4/3/2023. She continues to have considerable cervical, thoracic,
and lumbar pain.
Review of the cervical spine x-ray dated 5/1/2023 is notable for cervical spondylosis with multilevel
uncinate ridging and facet arthrosis with accompanying multilevel moderate neuroforaminal stenosis.
Review of the thoracic spine x-ray dated 5/1/2023 is notable for mild spondylosis in the lower thoracic
levels. Review of the lumbar spine x-ray dated 5/1/2023 is notable for multilevellumbar facet arthrosis,
along with trace anterolisthesis of L4 over L5 without evidence of dynamic instability.

Her cervical, thoracic, and lumbar spine pain presentations are most consistent with being facetogenic in
nature. She is a candidate for cervical/thoracic/lumbarfacet blocks leading up to potential radiofrequency
ablations at any time. However, for now she will continue physical therapy and follow-up with me in 2-3
weeks to reassess, at which time injection therapy may be considered. No medication refillsor new
prescriptions indicated at this time.

This Patient care visit occurred during a Public Health Emergency for Coronavirus/Covid-19. Therefore
this visit required additional personnel, time and supplies to maintain facial masking, social distancing,
temperature/symptom screening, and increased sanitation.
Kevin C. Pelletier, MD

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12/8/23, 8:48 AM

Communications

Orders Placed
None

Medication Changes
As of 5/5/2023 1:09 PM

None

Medication Listat End of Visit

As of 5/5/2023 1:09 PM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10% Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary: Cervical spondylosis M47.812
Thoracic spondylosis M47.814
Lumbarspondylosis M47.816
Acute post-traumatic headache, not intractable G44.319
Numbness and tingling of right lower extremity R20.0,R20.2
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecified street and highway as the place of occurrence of the external cause Y92.410

MRN:

Office Visit 8/2/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Peachtree Spine Physicians Primarydiagnosis: Lumbar spondylosis
Stonecrest Reason for Visit: Back Pain Toe Pain

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

PEACHTREE SPINE
PSP AND SPORTS PHYSICIANS

PEACHTREE SPINE PHYSICIANS STONECREST

8225 MALLPARKWAY,SUITE 250
LITHONIAGA 30038-7103
404-843-3323
Printed by Crissandra Webb at 12/8/2023 8:48 AM 11/23
12/8/23, 8:48 AM

Subjective:

Subjective
Patient ID: is a 65 y.o. female.

Chief Complaint:
Chief Complaint
Patient presents with
Back Pain
5/10
Toe Pain
RIGHT: 10/10

HPI
Patient is followingup after continued chiropractic treatment and due to recurring symptoms. Patient is
currently experiencing pain in their low-back and right lower extremity. The pain is continuous and
described as aching, throbbing, and burning.The symptoms are aggravated by sitting, standing, and
walking. Patient reports no associated symptoms in these areas.

Review of Systems
Constitutional: Negative for weight loss.
HENT: Negative for tinnitus.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for constipation and nausea.
Genitourinary:
No Incontinence
Musculoskeletal: Positive for back pain and neck pain.
Skin: Negative for rash.
Neurological: Positive for headaches. Negative for dizziness, seizures, loss of consciousness and
weakness.
Psychiatric/Behavioral: The patient has insomnia.

History reviewed. No pertinent past medical history.

Past Surgical History:
Procedure Laterality Date
APPENDECTOMY
URETER SURGERY

Family History
Problem Relation Age of Onset
Hyperlipidemia Other
Heartdisease Other
Cancer Other

Social History

Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Substance Use Topics
Alcohol use: Never

No Known Allergies
Current Outpatient Medications
Medication Sig Dispense Refill
capsaicin-methyl sal-menthol Apply 10 mLs 1 each 0
Printed by Crissandra Webb at 12/8/2023 8:48 AM 12/23
12/8/23, 8:48 AM

(NEW TEROCIN)0.025-25-10 topicallyas needed.

% Lotn
naproxen sodium (ALEVE)220 Take 220 mg by
MG tablet mouth in the
morning and 220 mg
before bedtime.
No current facility-administered medications for this visit.

Objective:
PHYSICAL EXAM
Gen: No acute distress, cooperative and pleasant
HEENT: Normocephalic, atraumatic
CV: Warm distal extremities, no pallor
Pulm: Non-labored breathing on room air, speaking in full sentences

LUMBAR SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in extension and flexion
Tenderness to palpation:
-Midline
-Bilateral lumbar paraspinals

Orders Placed This Encounter

MRIlumbar spine without contrast
Standing Status: Future
Standing Expiration Date: 8/2/2024
Order Specific Question: What is the patient's sedation requirement?
Answer: No Sedation

ICD-10-
CM
1. Lumbar spondylosis M47.816 MRIlumbar spine without contrast

2. Right leg paresthesias R20.2 MRIlumbar spine without contrast

3. Car driver injured in collision with other V43.52X MRIlumbar spine without contrast
type car in traffic accident, initial encounter A

4. Unspecifiedstreet and highwayas the Y92.410 MRIlumbar spine without contrast

place of occurrence of the external cause

Assessment & Plan:

Assessment
is a 65-year-old woman who presents for followup for injuries sustained as a direct result of a
motor vehicle accident that occurred on 4/3/2023. She continues to have significant low back pain and
shooting pain down the right lower extremity.Additionally,aside from tingling sensations alognt he
posterolateral aspect of the distal right lower extremity,she is also getting burning sensations along the
4th and 5th digits and lateral aspect of the right foot. Given her persistent symptoms despite extensive
conservative treatment, I would like to order an MRI fo the lumbar spine to rule out disc herniations. | will
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12/8/23, 8:48 AM

follow up with her in about 1 week to review the results of the above MRI,after which injection therapy
may be considered. No medication refillsor new prescriptions ordered this visit.

Kevin C. Pelletier, MD

Communications

Orders Placed
MRIlumbar spine without contrast

Medication Changes
As of 8/2/2023 1:22 PM

None

Medication List at End of Visit

As of 8/2/2023 1:22 PM
Refills Start Date End Date
capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10% Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary: Lumbar spondylosis M47.816
Right leg paresthesias R20.2
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecifiedstreet and highway as the place of occurrence of the external cause Y92.410

MRN:

Office Visit 8/9/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Peachtree Spine Physicians Primarydiagnosis: Spinal stenosis of lumbar region with radiculopathy
Stonecrest Reason for Visit: Back Pain Toe Pain

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

PEACHTREE SPINE
PSP ANDSPORTS PHYSICIANS

PEACHTREE SPINE PHYSICIANS STONECREST

8225 MALLPARKWAY,SUITE 250
LITHONIAGA 30038-7103
Printed by Crissandra Webb at 12/8/2023 8:48 AM 14/23
12/8/23, 8:48 AM

404-843-3323

Subjective:

Subjective
Patient ID: is a 65 y.o. female.

Chief Complaint:
Chief Complaint
Patient presents with
Back Pain
7/10
Toe Pain
RIGHT: 7/10

HPI
Patient is following up to review their L-Spine MRI. Patient is currently experiencing pain in their low-back
and right lower extremity.The pain is continuous and described as aching, throbbing, and burning. The
symptoms are aggravated by sitting, standing, and sneezing. Patient reports no associated symptoms in
these areas.
Review of Systems
Constitutional: Negative for weight loss.
HENT: Negative for tinnitus.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain and leg swelling.
Gastrointestinal: Negative for constipation and nausea.
Genitourinary:
No Incontinence
Musculoskeletal: Positive for back pain and neck pain.
Skin: Negative for rash.
Neurological: Positive for headaches. Negative for dizziness, seizures, loss of consciousness and
weakness.
Psychiatric/Behavioral: The patient has insomnia.

History reviewed. No pertinent past medical history.

Past Surgical History:
Procedure Laterality Date
APPENDECTOMY
URETER SURGERY

Family History
Problem Relation Age of Onset
Hyperlipidemia Other
Heart disease Other
Cancer Other

Social History

Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Substance Use Topics
Alcohol use: Never

No Known Allergies
Current Outpatient Medications
Medication Sig Dispense Refill

Printed by Crissandra Webb at 12/8/2023 8:48 AM 15/23

12/8/23, 8:48 AM

capsaicin-methyl sal-menthol Apply 10 mLs 1 each 0

(NEW TEROCIN) 0.025-25-10 topicallyas needed.
% Lotn
naproxen sodium (ALEVE)220 Take 220 mg by
MG tablet mouth in the
morning and 220 mg
before bedtime.
No current facility-administered medications for this visit.

Objective:

PHYSICAL EXAM
Gen: No acute distress, cooperative and pleasant
HEENT: Normocephalic, atraumatic
CV: Warm distal extremities, no pallor
Pulm: Non-labored breathing on room air, speaking in full sentences
Neuro:
-Strength: 5/5 throughout bilateral lower extremities
-Sensation: Intactthroughout bilaterallower extremities with the exception of diminished sensation
along the RIGHTL5 dermatome
-Reflexes:
-DTRs: 2+ and symmetric throughout bilateral lower extremities
-UMNsigns: Negative for ankle myoclonus bilaterally

LUMBAR SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in flexion and extension
Tenderness to palpation:
-Midline
-Bilateral lumbar paraspinals

Orders Placed This Encounter

Amb referral to Physical Therapy Eval&Tr
Referral Priority: Routine
Referral Type: Physical Medicine
Referral Reason: Specialty Services Required
Requested Specialty: Physical Therapist
Number of Visits Requested: 1
PSP Referral to SURGERY SCHEDULER
Referral Priority: Routine
Referral Type: Surgical
Referral Reason: Specialty Services Required
Number of Visits Requested: 1

ICD-10-
CM
1. Spinal stenosis of lumbarregion with M48.061 Amb referral to Physical Therapy
radiculopathy Eval&Tr
M54.16 PSP Referral to SURGERYSCHEDULER
CANCELED:PSP Referral to SURGERY
SCHEDULER

2. Car driver injured in collision with other V43.52X Amb referral to Physical Therapy Eval&Tr
type car in traffic accident, initialencounter A
PSP Referral to SURGERY SCHEDULER
CANCELED:PSP Referral to SURGERY
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12/8/23, 8:48 AM

SCHEDULER

3. Unspecifiedstreet and highway as the Y92.410 Amb referralto Physical Therapy Eval&Tr
place of occurrence of the external cause
PSP Referral to SURGERY SCHEDULER
CANCELED:PSP Referral to SURGERY
SCHEDULER

Assessment & Plan:

Assessment
is a 65-year-old woman who presents for follow up for injuriessustained as a direct result of a
motor vehicle accident that occurred on 4/3/2023. She received chiropractic care followingthe accident.
She continues to have severe low back pain with pain down the backs of both lower extremities, but with
numbness in the distal right lower extremity involvingthe lateral aspect of the foot. Review of the lumbar
spine MRIdated 8/4/23 is notable for the following:
-At L1/2,there is right greater than left facet hypertrophy
-AtL2/3, there is bilateral facet hypertrophy
-At L3/4, there is a broad-based disc bulge and bilateralfacet hypertrophythat results in moderate-to-
severe central stenosis and up to moderate bilateralforaminalstenosis; annulartear
-AtL4/5, there is grade 1 anterolisthesis contributing to severe central stenosis, moderate-to-severe
bilateralforaminalstenosis, severe impingement of bilateralL5 nerve roots; annulartear
Her presentation is consistent with aggravation of a subclinical preexisting condition. Moreover, her low
back pain presentation is consistent with lumbar radiculopathy affecting the primarilythe right lower
extremity. She is a candidate for a RIGHT L5 transforaminal epidural steroid injection at any time. I would
also like her to begin a course of physical therapy for lumbar stabilization. I willfollow up with her in 2
weeks after the above proposed injectionto assess her response to injectiontherapy and to see how
physical therapy is going for her.

Kevin C. Pelletier, MD

Communications

Orders Placed
Amb referral to Physical Therapy Eval&TrNew Request
PSP Referral to SURGERYSCHEDULEROrder Changed

Medication Changes
As of 8/9/2023 1:58 PM

None

Medication List at End of Visit

As of 8/9/2023 1:58 PM
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12/8/23, 8:48 AM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
% Lotn
25-10 %
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary:Spinal stenosis of lumbar region with radiculopathy M48.061, M54.16
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecifiedstreet and highway as the place of occurrence of the external cause Y92.410

MRN:

Procedure visit 11/7/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Optimum Spine Center Primarydiagnosis: Spinal stenosis of lumbar region with radiculopathy
Reason for Visit: Referred by Kevin C Pelletier, MD

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

Procedure Orders
1. Injection Procedure ] ordered by Kevin C Pelletier, MD
Post-procedure Diagnoses
1. Spinal stenosis of lumbar region with radiculopathy [M48.061, M54.16]
2. Car driver injured in collision with other type car in traffic accident, initial encounter [V43.52XA]
3. Unspecified street and highway as the place of occurrence of the external cause [Y92.410]

PSP PEACHTREE
AND SPORTS
SPINE
PHYSICIANS

OPTIMUMSPINE CENTER
5555 PEACHTREE DUNWOODY ROAD NE
SUITE G99
ATLANTAGA 30342-1700
404-843-3323
Patient Name:
DOB:
Today's Date: 11/7/2023
Date of Service: 11/7/2023
Injection Procedure

Date/Time: 11/7/2023 10:43 AM

Performed by: Kevin C Pelletier, MD

Authorized by: Kevin C Pelletier, MD

Indications: The patient has low back pain radiating into the affected lower extremity. The patient is
functionally limited with walking. Diagnostic imaging reveals a lumbar herniated disc with correlating
stenotic pathology. The patient has continued pain after a trial of therapeutic exercise. We willproceed
with a lumbar epidural steroid injection to decrease pain and improve functional activity.

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12/8/23, 8:48 AM

The patient has undergone a history and physical examination performed by me, and is medically cleared
to proceed with today's procedure in the ASC.

Despite the risks of bleeding, hematoma, infection, paralysis, nerve injury,death, increased pain,
pneumothorax, ecchymosis, and/or headache, informedconsent was obtained. The patient was taken to
the fluoroscopy suite and placed on the table in the desired position. The skin was prepped and draped in
a sterile fashion. The side of procedure (location) was verified, and marked by the physician prior to the
start of the procedure.

Anesthesia: The patient is experiencing significant anxiety and has difficultylying in the required position.
Therefore, it is medically necessary to provide anesthesia care and sedation in order to proceed with this
procedure. Withoutthe monitored sedation, it is felt that this procedure would place the patient at an
increased risk secondary to an inabilityto lie in the required position. The undersigned provided moderate
sedation in this case, as detailed hereinafter. Atrained observer, who is a nurse, assisted in the
monitoring of the patient's level of consciousness and physiological status (includingcardiac monitoring),
recorded on a separate record in the medical chart. 25 mcg of Fentanyl and 2 mg of Versed were
administered to the patient in the procedure room in my presence, and at my direction by the nurse. The
patientreached a depressed level of consciousness as a resultof these medications.

Anesthesia: 1% lidocaine

Anesthesia: Ethyl Chloride

Right L5 Transforaminal Epidural Steroid Injection:

Under fluoroscopic guidance, a spinal needle was advanced in a posterior to anterior and slightlyoblique
trajectory such that when viewed on AP fluoroscopic imaging, the needle tip was placed lateral to the six
o'clock position of the right L5 pedicle. Contrast injected at this level and revealed proximal epidural flow
in a nonvascular pattern. A solution of 10mg of Dexamethasone and 1% lidocaine was injected at this
level.

The patient tolerated the procedure well.There were no immediate or obvious complications.
The patient may follow-upas scheduled.
Kevin C. Pelletier, MD

Instructions
After Visit Summary (Automatic SnapShot taken 11/7/2023)

Additional Documentation

Flowsheets: Treatment Log

Orders Placed
Injection Procedure (Resulted 11/7/2023)

Medication Changes
As of 11/7/2023 10:44 AM

None

Medication List at End of Visit

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12/8/23, 8:48 AM

As of 11/7/2023 10:44 AM
Refills Start Date End Date
capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary:Spinal stenosis of lumbar region with radiculopathy M48.061, M54.16
Car driver injured in collision with other type car in traffic accident, initial encounter V43.52XA
Unspecified street and highway as the place of occurrence of the external cause Y92.410

Office Visit 11/20/2023 Provider: Kevin C Pelletier, MD (Physical Medicine & Rehabilitation)
Peachtree Spine Physicians Primarydiagnosis: Spinal stenosis of lumbar region with radiculopathy
Stonecrest Reason for Visit: Back Pain; Referred by Benjamin Abraham

Progress Notes Kevin C Pelletier, MD (Physician) Physical Medicine & Rehabilitation

PEACHTREE SPINE
PSP AND SPORTS PHYSICIANS

PEACHTREE SPINE PHYSICIANS STONECREST

8225 MALLPARKWAY,SUITE 250
LITHONIAGA 30038-7103
404-843-3323

Subjective:

Subjective
Patient ID: is a 66 y.o. female.

Chief Complaint:
Chief Complaint
Patient presents with
Back Pain
2/10 up to 7/10 withprolonged sitting

Patient is following up after an injection. Patient is currently experiencing pain in their mid-back and low-
back. The pain is continuous and described as stabbing. The symptoms are aggravated by sitting. Patient
reports no associated symptoms in these areas.

Review of Systems
Gastrointestinal: Negative for constipation and nausea.
Genitourinary: Negative for frequency.
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12/8/23, 8:48 AM

Musculoskeletal: Positive for back pain and myalgias.

History reviewed. No pertinent past medical history.

Past Surgical History:
Procedure Laterality Date
APPENDECTOMY
CERVIX SURGERY
HYSTERECTOMY
URETER SURGERY

Family History
Problem Relation Age of Onset
Brain cancer Mother
Cancer Father
Brain cancer Sister
Hyperlipidemia Other
Heart disease Other
Cancer Other

Social History

Tobacco Use
Smoking status: Never
Smokeless tobacco: Never
Substance Use Topics
Alcohol use: Never

No Known Allergies
Current Outpatient Medications
Medication Sig Dispense Refill
capsaicin-methyl sal-menthol Apply 10 mLs 1 each 0
(NEW TEROCIN)0.025-25-10 topicallyas needed.
% Lotn
naproxen sodium (ALEVE)220 Take 1 tablet (220
MG tablet mg total) by mouth in
the morning and 1
tablet (220 mg total)
before bedtime.

No current facility-administered medications for this visit.

Objective:
PHYSICAL EXAM
Gen: No acute distress, cooperative and pleasant
HEENT: Normocephalic, atraumatic
CV: Warm distal extremities, no pallor
Pulm: Non-labored breathing on room air, speaking in full sentences

LUMBAR SPINE
Inspection:
-No surgical scars, swelling, or bruising
Active range of motion:
-Limited in flexion and extension
Tenderness to palpation:
-Midline
-Bilateral lumbar paraspinals

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12/8/23, 8:48 AM

No orders of the defined types were placed in this encounter.

ICD-10-
CM
1. Spinal stenosis of lumbar region with M48.061
radiculopathy
M54.16

2. Car driver injured in collision with other V43.52X

type car in traffic accident, subsequent D
encounter

3. Unspecified street and highway as the Y92.410

place of occurrence of the external cause

Assessment & Plan:

Assessment
is a 65-year-old woman who presents for follow up for injuries sustained as a direct result of a
motor vehicle accident that occurred on 4/3/2023. She received chiropractic care followingthe accident.
She also underwent a right L5 transforaminal epidural steroid injection on 11/7/23. She reports 50% pain
relief followingthe injection. Her pain can now be as low as 2/10 and much less frequently gets up
around a 7/10. She has been doing stretching and strengthening exercises for her neck and low back at
home. She also recently started dieting and trying to be more active. Overall, she is encouraged about
her progress and her current state of reduced symptoms. I have encouraged her to continue her home
exercises program. She can return to cliniconly as needed at this point should her pain again worsen.
No medication refills or new prescriptions needed at this time.

Kevin C. Pelletier, MD

Instructions
Return if symptoms worsen or fail to improve.
After VisitSummary (Automatic SnapShot taken 11/21/2023)

Communications
AMBVisit Report sent to Benjamin Abraham, DO
Sent 11/21/2023

Orders Placed
None

Medication Changes
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12/8/23, 8:48 AM

As of 11/20/2023 2:15 PM
None

Medication List at End of Visit

As of 11/20/2023 2:15 PM

Refills Start Date End Date

capsaicin-methyl sal-menthol (NEWTEROCIN)0.025- 0 4/28/2023
25-10 % Lotn
Apply 10 mLs topically as needed. - Topical (Top)
naproxen sodium (ALEVE)220 MG tablet
Take 1 tablet (220 mg total) by mouth in the morning and 1 tablet (220 mg total) before bedtime. - Oral
Patient-reported medication

Visit Diagnoses
Primary:Spinal stenosis of lumbar region with radiculopathy M48.061, M54.16
Car driver injured in collision with other type car in traffic accident, subsequent encounter V43.52XD
Unspecifiedstreet and highway as the place of occurrence of the external cause Y92.410

Printed by Crissandra Webb at 12/8/2023 8:48 AM 23/23

 PSP PEACHTREE
AND SPORTS
SPINE
PHYSICIANS
ACR
RADIOLOGY

Patient Name: Date of birth:

Patient ID: Study Description: LUMBAR SPINE XR
Study Date: 05/01/2023 11:54:22 AM Ref. Phy.: KEVIN PELLETIER, MD
Sex: Female

HISTORY: Lumbar Spine Pain S/P MVA 4/4/23

LUMBAR SPINE RADIOGRAPHS

CLINICAL HISTORY: Lumbar Spine Pain S/P MVA 4/4/23

COMPARISONS: None

VIEWS: 5

FINDINGS:

Trace anterolisthesis L4 on L5 without evidence of dynamic instability. Multilevel

lumbar facet arthrosis is observed with additional thoracic spondylosis. No acute fracture
or traumatic subluxation. No destructive osseous process.

IMPRESSION:

Trace anterolisthesis L4 on L5 without evidence of dynamic instability or acute

osseous abnormality.

Dr. Kevin Goelz 5/2/2023 6:59 PM

Page 1 of 2
Patient Name: Date of birth:
Patient ID: Study Description: LUMBARSPINE XR
Study Date: 05/01/2023 11:54:22 AM Ref. Phy.: KEVIN PELLETIER, MD
Sex: Female

HISTORY:Lumbar Spine Pain S/P MVA 4/4/23

Extension

EO 4.18 cm

Page 2 of 2
 RESONANCE

PSP PEACHTREE
AND SPORTS
SPINE
PHYSICIANS
ACR
RADIOLOGY

Patient Name: Date of birth:

Patient ID: Study Description: CERVICAL SPINE XR
Study Date: 05/01/2023 11:47:10 AM Ref. Phy.: KEVIN PELLETIER, MD
Sex: Female

HISTORY: Cervical Spine Pain S/P MVA 4/4/23

CERVICAL SPINE RADIOGRAPHS

CLINICAL HISTORY: Cervical Spine Pain S/P MVA 4/4/23

COMPARISONS: None

VIEWS: 7

FINDINGS:

Straightening of normal cervical lordosis observed without fractureor traumatic

subluxation. Multilevel uncinate ridging and facet arthrosis with accompanying
multilevel moderate severity neuroforaminal stenosis. Lung apices are clear. No focal-
month-old odontoid abnormality although the odontoid tip is not well seen. No evidence
of dynamic instability on flexion or extension imaging.

IMPRESSION:
Cervical spondylosiswithout acute posttraumatic abnormality.

Dr. Kevin Goelz 5/2/2023 3:17 PM

Page 1 of 1
 PSP PEACHTREE
AND SPORTS
SPINE
PHYSICIANS
ACR
RADIOLOGY

Patient Name: Date of birth:

Patient ID: Study Description: THORACIC SPINE XR
Study Date: 05/01/2023 11:52:21 AM Ref. Phy.: KEVIN PELLETIER, MD
Sex: Female

HISTORY: Thoracic Spine Pain S/P MVA 4/4/23

THORACIC SPINE RADIOGRAPHS

CLINICAL HISTORY: Thoracic Spine Pain S/P MVA 4/4/23

COMPARISONS: None

VIEWS: 3

FINDINGS:

Thoracic vertebral body heights and alignment are grossly maintained without fracture or
traumatic subluxation. Heart size is normal. Lungs are clear. No significant additional
findings observed.

IMPRESSION:

No acute posttraumatic abnormality.

Dr. Kevin Goelz 5/2/2023 3:19 PM

Page 1 of 1