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Assignment:
18- The patient, a 52-year-old female, is referred by her family practice physician to the neurologist for a consultation for the referral as "possible spasmodic torticollis". Upon examination, the neurologist found the patient's neck muscles were contracted involuntary, causing her head to turn to one side with her chin pointing toward her shoulder. The neurologist learned by taking the patient's history that the patient's mother had the same condition for the past ten years of her life. The neurologist concluded the patient had spasmodic torticollis. The patient was very upset and frightened that she would have the same fate as her mother. The neurologist reassured the patient there are more treatments available to her than were available to her mother 30 years ago.
The patient was given a prescription for mild muscle relaxant, prescription for physical therapy, and an order for the fitting of a special neck brace. The neurologist recommended injections of botulinum toxin into the affected muscles but the patient wanted to think it over and was asked to make a follow-up appointment in one month or sooner if she decided to have the Botox injections. The patient was also given information about the National Spasmodic Torticollis Association, that offers patient education and support to people with spasmodic Torticollis.
Two ICD 10 2021 codes are required
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