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 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
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.
Range of Motion
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
Pt able to ambulate without assistive device with antalagic gait & L LE ER. Single leg stance: R >30 seconds, L 2-3 seconds
|ball of foot
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