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