Radiculopathy

Patient presents with complaints consistent with radiculopathy.  Symptoms include radiating pain, numbness, tingling, and or weakness.  The location of the radicular symptoms suggests potential involvement of the (specify cervical, thoracic, or lumbar) spine.  Onset of symptoms was (date of onset and describe onset  e.g., gradual, sudden, after lifting heavy object).  Pain quality is described as (sharp, burning, aching, electric) and radiates from (specify location, e.g., neck into right arm, low back into left leg).  Physical examination reveals (positive or negative) Spurling's maneuver, (positive or negative) straight leg raise test, and diminished reflexes in (specify dermatome, myotome, e.g., C6, L5).  Differential diagnoses include herniated disc, spinal stenosis, nerve root compression, and degenerative disc disease.  Assessment includes radiculopathy likely secondary to (presumed etiology, e.g., disc herniation, foraminal stenosis).  Plan includes (conservative or surgical) management.  Conservative treatment options include NSAIDs for pain management, physical therapy referral for range of motion and strengthening exercises, and patient education on proper body mechanics.  If conservative treatment fails, consideration will be given for further imaging such as MRI or CT scan to assess nerve root compression and potential surgical intervention.  Patient was prescribed (medication name and dosage) and instructed to follow up in (timeframe) to assess response to treatment.  Diagnosis codes considered include (list relevant ICD-10 codes, e.g., M54.12, M54.16).  Medical necessity for diagnostic testing and treatment plan explained to the patient.