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Botox Treatment Plan

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DOI: 6/21/2014. The patient is a 52-year-old right-handed female technician who sustained a work-related injury to when metal paper holder sprung out and hit her. She did not lose consciousness but was disoriented and confused.

Based on the latest medical report dated 02/27/16, the patient reports that after the injury, she had headaches on the right side of the head and had tinnitus almost right away. She developed blurry vision the next day, nausea disruptions to balance and hearing changes on the right side. She had a computed axial tomography scan done which was negative, was referred to neurology and was taken out of work for 2 months. She is currently getting Botox injections every 4 months which is helping her headaches and associated neck problems as well. Her neck problems seem to be worsening over time. They are more obviously dysfunctional when her Botox relieves some …show more content…

Impressions are post concussion syndrome, memory loss or impairment, vestibular hypofunction and right tinnitus.
Treatment plan includes scheduling impact and sway to assess fully balance disruption as well as screening and neurocognitive testing, referral to vestibular therapy for initial evaluation, referral to ear, nose and throat (ENT) specialist and to start PT. Baclofen will be changed from ½ tablet 3 times daily to 1 tablet at night.
On the statement of medical necessity on the C-4 form dated 03/10/16, the patient requires vestibular/vision therapy services due to pronounced vestibular hypofunction symptoms and/or abnormal optokinetic integration symptoms as a result of mild traumatic brain injury/concussion. These are common findings after a concussion and while mild version will resolves spontaneously, a certain percentage of patients will require therapy. Therapy of these findings will allow for better symptom control as well as faster resolution and should be started once the patient is able to tolerate

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