Kenny Nunn - 505TH - 11.30.2023

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2/16/24, 1:56 PM Encounter - Office Visit Date of service: 11/30/23 Patient: Kenny Nunn DOB: 03/11/1957 PRN: NK726656

PATIENT FACILITY ENCOUNTER


Kenny Nunn 505Therapy Office Visit
DOB 03/11/1957 T (505) 361-1931 NOTE TYPE SOAP Note
AGE 66 yrs 3911 4th Street NW SEEN BY Rebekah Khan
SEX Male Suite A DATE 11/30/2023
PRN NK726656 Albuquerque, NM 87107 AGE AT DOS 66 yrs
Electronically signed by Rebekah Khan at
01/11/2024 02:22 pm

Vitals for this encounter


No vitals recorded

Diagnoses
Was diagnosis reconciliation completed?
No selection made
Current ACUITY START STOP
(R27.9) Unspecified lack of coordination
(R42) Dizziness and giddiness
(H53.2) Diplopia
(H53.71) Glare sensitivity
(R41.3) Other amnesia
(H93.239) Hyperacusis, unspecified ear
(R41.89) Other symptoms and signs involving cognitive functions
and awareness
(M54.2) Cervicalgia
(M54.50) Low back pain, unspecified
(M25.511) Pain in right shoulder
(H53.8) Other visual disturbances
(G47.9) Sleep disorder, unspecified
(S00.83XA) Contusion of other part of head, initial encounter
Historical ACUITY START STOP
No historical diagnoses

Subjective
Kenny Nunn 03/11/1957 66 yrs

Date of injury: 08/30/2023

Description of injury: Motor vehicle accident

The patient presents to the clinic for their 5th session of neuro biofeedback therapy. Secondary to the accident, the patient is
experiencing post-headache, nausea, lack of coordination, dizziness, double vision, blurry vision, glare sensitivity, hyperacusis,
fatigue, nervousness, anxiety, amnesia, tinnitus, cognitive dysfunction, and contusion of the head.

ROS: The patient denies vomiting, sinus pressure, slurred speech, seizures, tremors, palpitations, and shortness of breath.
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2/16/24, 1:56 PM Encounter - Office Visit Date of service: 11/30/23 Patient: Kenny Nunn DOB: 03/11/1957 PRN: NK726656

Objective
Neuro Biofeedback Therapy:
The Neuro Optimal System is a software program designed to expose the patient to both visual and auditory stimuli while
simultaneously recording the frequencies emitted by the brain. When the recorded frequencies do not match the expected
frequencies, the program will respond by interrupting the stimuli for 1-3 milliseconds. This interruption sends a signal to the brain
that there is an abnormality in the brain's functionality. Over time, the brain is expected to gradually make corrections until
returning to the expected frequency. This therapy is most beneficial for patients suffering from post-concussion symptoms, PTSD,
anxiety, and depression.

Technique:
Electrodes are adhered with conductive gel on the patient's head and ears. One electrode was placed on the superior aspect of the
outer ear (bilaterally), one electrode was placed on the parietal scalp (bilaterally), and the final electrode (ground) was placed on the
right earlobe. These electrodes were then connected to the Neuro Optimal system which transmitted the signal to the screen where
the frequencies emitted by the patient's brain were displayed. After 30 minutes of stimuli, the electrodes were removed.

The patient completed the treatment outline above.


Assessment

Diagnoses attached to this encounter:


Lack of coordination [ICD-10: R27.9], [ICD-9: 781.3], [SNOMED: 281016006]
Dizziness [ICD-10: R42], [ICD-9: 780.4], [SNOMED: 404640003]
Double vision [ICD-10: H53.2], [ICD-9: 368.2], [SNOMED: 24982008]
Glare sensitivity [ICD-10: H53.71], [ICD-9: 368.8], [SNOMED: 64445006]
Amnesia [ICD-10: R41.3], [ICD-9: 780.93], [SNOMED: 48167000]
Hyperacusis [ICD-10: H93.239], [ICD-9: 388.42], [SNOMED: 25289003]
Cognitive dysfunction [ICD-10: R41.89], [ICD-9: 294.9], [SNOMED: 386806002]
Cervicalgia [ICD-10: M54.2], [ICD-9: 723.1], [SNOMED: 81680005]
Lumbar pain [ICD-10: M54.50], [ICD-9: 724.2], [SNOMED: 279039007]
Pain in right shoulder [ICD-10: M25.511], [ICD-9: 719.41], [SNOMED: 15917011000119100]

Plan
Recommended: Continue with neuro biofeedback therapy

Neuro Biofeedback Therapy: Our program designed to expose the patient to both visual and auditory stimuli while simultaneously
recording the frequencies emitted by the brain. When the recorded frequencies do not match the expected frequencies, the
program will respond by interrupting the stimuli for 1-3 milliseconds. This interruption sends a signal to the brain that there is an
abnormality in the brain's functionality. Over time, the brain is expected to gradually make corrections until returning to the
expected frequency. This therapy is most beneficial for patient's suffering from post-concussion symptoms, PTSD, anxiety, and
depression.

Orders
LAB ORDERS
No orders attached to this encounter.
IMAGING ORDERS
No orders attached to this encounter.

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