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: 7/27/99
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 22: ; Cancels/No Shows: 0
TREATMENT CONSISTS OF:
ROM/Stretching, Strengthening, Muscle Re-education, Gait Training, Patient Education, Instruction in Home Program,, Electric Stimulation, Ice, Joint Mobilization
SUBJECTIVE REPORTS:
Pt reports he is able to ascend stairs reciprocally, ambulate with cane with increased ease, be on L LE 45-60 minutes, and has decreased overall "ache" in L LE. Pt cont. with difficulty descending stairs reciprocally, squatting/getting down on knees & cont with L ankle & knee pain. Pt with 60% subjective improvement.
OBJECTIVE:
Range of Motion
| L Knee: |
AROM |
0-124º |
|
PROM |
0-135º |
| L ankle: |
PF: |
36º |
Inv: |
17º
|
|
DF: |
12º |
Ev: |
18º |
Strength: hip flex 4+/5; knee flex 4/5 ext 4/5; ankle PF 4/5 Inv 3+/5, DF 4-/5 EV 3+/5
Girth Measurement:
| midpatella |
45.0cm |
| 10cm below |
43.3cm |
| 10cm above |
50.8cm |
| midmalleolar |
31.4cm |
| ball of foot |
25.1cm |
Pt able to ambulate without assistive device with antalagic gait & L LE ER. Single leg stance: R >30 seconds, L 2-3 seconds
COMMENTS/RECOMMENDATIONS:
This pt has been seen x22 visits & cont to show progress with PT with increased strength/ROM, reduced edema & increased functional mobility. Mr. Fleming presents with functional ROM & strength of L knee & improved L ankle ROM in all planes by at least 10-20 degrees since initial evaluation. Pt cont, however, with decreased L ankle strength as above, decreased ability to perform L single leg stance, & ultimately decreased ability to ambulate without an assitive device (shorthand symbol) to decreased L LE balance & proprioception. Pt may benefit from cont PT to address these deficits & promote normal strength & gait. Please advise accordingly.
Amy R., MPT