DOI: 4/1/2016. Patient is a 32-year-old female receiving clerk who sustained injury to her left knee resulting to a tear in the anterior cruciate ligament (ACL) and medial collateral ligament. Per OMNI entry, he underwent surgery on 07/13/16.
Per the PT daily note dated 10/20/16, IW has attended 5 sessions for the knee.
Based on the progress report dated 11/11/16 by Dr. Woodson,, the patient reports that her pain is dull and throbbing in nature. She rates the level of her pain as about 3 out of 10 on a pain scale. It is on an occasional basis. The pain is worse with standing from long periods of time and walking for a distance. Sitting decreases her pain. She is taking
Tylenol and naproxen on an as needed basis. Of note, X-rays …show more content…
There is a positive anterior drawer sign and a positive Lachrnan maneuver. Pivot shift test for rotatory instability is positive. All these tests are excruciatingly painful.
She reports a height of 5 feet, 7 inches and a weight of 200 pounds
Assessments include the following: left knee degenerative joint disease, severe; left knee genu varum; exacerbation of post-traumatic arthritis to the left knee; and industrial injury to the left knee with exacerbation of preexisting condition. Patient has elected for a left total knee replacement.
Treatment plan includes left total knee replacement, a two-day hospital stay, a front-wheeled walker, a raised toilet seat, a cold therapy unit for a 21-dayrental versus a home purchase, a set ofMobilegs crutches and postoperative physical therapy two times per week for six weeks.
Requested from the provider’s office copies of MRI/X-ray reports; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 1 Left Total Knee Replacement; 1 Medical Clearance; 2 Days In-patient Hospital Stay; and 12 Post-Operative Physical Therapy Sessions for the Left Knee between 11/28/2016 and 1/27/2017.
This is 1 out of 2
Per the PT daily note dated 10/20/16, IW has attended 5 sessions for the knee.
Based on the progress report dated 11/11/16 by Dr. Woodson,, the patient reports that her pain is dull and throbbing in nature. She rates the level of her pain as about 3 out of 10 on a pain scale. It is on an occasional basis. The pain is worse with standing from long periods of time and walking for a distance. Sitting decreases her pain. She is taking
Tylenol and naproxen on an as needed basis. Of note, X-rays …show more content…
There is a positive anterior drawer sign and a positive Lachrnan maneuver. Pivot shift test for rotatory instability is positive. All these tests are excruciatingly painful.
She reports a height of 5 feet, 7 inches and a weight of 200 pounds
Assessments include the following: left knee degenerative joint disease, severe; left knee genu varum; exacerbation of post-traumatic arthritis to the left knee; and industrial injury to the left knee with exacerbation of preexisting condition. Patient has elected for a left total knee replacement.
Treatment plan includes left total knee replacement, a two-day hospital stay, a front-wheeled walker, a raised toilet seat, a cold therapy unit for a 21-dayrental versus a home purchase, a set ofMobilegs crutches and postoperative physical therapy two times per week for six weeks.
Requested from the provider’s office copies of MRI/X-ray reports; however, no callback/report was received prior to the submission of this request to PA.
Current request is for 1 Left Total Knee Replacement; 1 Medical Clearance; 2 Days In-patient Hospital Stay; and 12 Post-Operative Physical Therapy Sessions for the Left Knee between 11/28/2016 and 1/27/2017.
This is 1 out of 2