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