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

INITIAL EVALUATION


Name: Wes Fleming
Age: 29
Occupation: Technical trainer, presently working from home
Date: 5/21/99
Referring MD: Schwartzbach
MD Recheck: 5/27/99
Date of Surgery: 5/11/99
Date of Injury: 5/11/99
Diagnosis: Fracture left tibia. Status post rod and screw implementation.

SUBJECTIVE:

Mechanism of Injury/Recent Exacerbation: Patient reports he was on his motorcycle and was hit by a car on 5/11/99. Patient underwent surgery for fracture tibia with rod and screw implementation on 5/11/99.

Chief Complaint/Functional Limitations: Patient with complaint on left foot pain secondary to swelling. Patient with complains of pain with changes in position, with foot down for prolonged periods and with movement of ankle and knee.

Past Medical History: None reported with exception of left fracture elbow and low back injury in 8th grade.

Pain Scale: 3/10 now; 6/10 worst

Tests: X-rays taken 5/11/99 and 5/20/99

Medications: Vicoden, Lovenox, Celexa (anti-depressant).

Prior Activity Level/Functional Status: Full and painfree activities of daily living, work, and leisure activities.

OBJECTIVE:

Observation/Posture/Gait: Patient ambulating non weight bearing left lower with axillary crutches. Patient with significant fatigue with ambulation greater than 100 ft. Patient with healing incision left knee and medial ankle. Patient with drainage from wound anterior tibia and post tibia, however dressing not removed secondary to allow healing. Patient with significant pitting edema from inferior knee to foot on left.

Range of Motion/Flexibility/Active:
Left knee AROM: 10-92º
PROM: 8-103º
Right knee AROM: 0-135º
PROM: 0-140º
Right ankle plantarflexion: 45º inversion: 35º
dorsiflexion: 10º eversion: 30º
Left ankle plantarflexion: 45º inversion:
dorsiflexion: -10º eversion:

Strength: Right lower extremity 5/5. Left hip flexion 4/5, knee extension 4-/5, flexion 4-/5, ankle not tested secondary to recent surgery.

(page 2)

Girth/Swelling:
Loc. Right Left
Mid patella 44.5cm 47.2cm
10cm below 40.6cm 48.0cm
10cm above 49.8cm 35.0cm
Mid malleolar 28.6cm 35.0cm
Ball of foot 25.5cm 28.7cm

Palpation: not tested due to recent surgery.

Special Test/Neuro: Patient able to perform straight leg raise lower left extremity.

Treatment/Initial Visit: Evaluation; home exercise program of ankle pumps, ankle ROM, heel slides and use of ice; ice and elevation; tubigrip size F.

ASSESSMENT: Patient is a 29 year old male status post left tibia fracture with rod and screw implementation on 5/11/99. Patient presents to the clinic with pain, edema, decrease ROM, decrease strength, and decrease functional mobility secondary to recent surgery.

PLAN: home exercise program, edema control, ROM, strengthening, gait training, wound management.

Frequency/Duration: 2 times per week for 5 weeks.

Goals:
STG (#2 weeks) Patient will be independent with ROM home exercise program
Patient will be independent with icing and elevation
Decrease edema left lower extremity by at least 2cm
LTG (#4 weeks) Patient will be able to ambulate 200' with crutches
Patient will be able to tolerate gently strengthening
Increase ankle ROM left by at least 50%

Physical Therapist: Amy R.

AR/jrp1