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
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
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.
Range of Motion
||2 - 113º
||0 - 122º
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
Pt able to ambulate with straight cane (shorthand symbol) step to gait pattern.
|ball of foot
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