This is a transcript of a report from my medical records. Misspelled words and bad grammar has been transcribed as well.
INOVA Rehabilitation Center, Woodbridge VA
Physical Therapy
Physician Update
Doctor: Schwartzbach
Date: 6/22/99
Your patient Wes Fleming has been attending his physical therapy.
Diagnosis: Fx L tibia (s/p hardware implementation)
Dates of Treatment: May 21, 1999 - present
Attendance: Number of treatments 11: ; Cancels/No Shows: 0
TREATMENT CONSISTS OF:
ROM/Stretching, Strengthening, Muscle Re-education, Gait Training, Patient Education, Instruction in Home Program, Ice
SUBJECTIVE REPORTS:
Pt reports he is now able to stand on L LE (ed. note: lower extremity) for 15-20 minutes, ambulate with use of cane, sleep & move L LE (shorthand symbols) as needed. Pt continues to complain of pain L ankle even at rest. Decreased ROM L ankle, difficulty with ambulating FWB 2 to pain & c/o L knee pain.
OBJECTIVE:
Range of Motion
| L Knee: |
AROM |
2 - 113º |
|
PROM |
0 - 122º |
| L ankle: |
PF: |
25º |
Inv: |
10º
|
|
DF: |
0º (neutral) |
Ev: |
11º |
Strength: hip flex 4+/5, knee flex 4-/5 ext 4-/5, ankle PF 3+/5 Inv 3/5 DF 3+/5 Ev 3+/5
Girth Measurement:
| midpatella |
44.7cm |
| 10cm below |
43.2cm |
| 10cm above |
48.8cm |
| midmalleolar |
32.7cm |
| ball of foot |
26.5cm |
Pt able to ambulate with straight cane (shorthand symbol) step to gait pattern.
COMMENTS/RECOMMENDATIONS:
Pt has been seen x 11 visits & has made excellent progress in PT thus far. Pt presents with increased strength, increased ROM, decreased pain, decreased edema & increased functional mobility. Pt, however continues to have deficits in ankle ROM & strength, knee ROM & strength, ambulation (shorthand symbols) for prolonged distances, & decreased joint movement at L ankle. Pt would benefit from continued PT to address above deficits & progress functional strength & mobility. Rx to include stretching, joint mobs, strengthening & funtional activities x 3-4 weeks.
Amy R., MPT