DOI: 06/22/2014. The patient is a 37-year-old male laborer who sustained injury while pushing a pallet jack off a truck and took a step over the truck to the ground doing the splits. The patient is subsequently diagnosed with status post left tibia puncture fracture repair with instrumentation, left knee, left ankle, lumbar sprain/strain.
Based on the progress report by Dr. McSweeney dated 01/07/16, the patient had a left ankle scope on 12/17/15 and has just started PT. He reports left ankle pain rated as 3-4/10 and feels stiff. He has a pulling pain on the left posterior knee with grinding sensation. He is unable to kneel.
On examination of the left knee, there is tracking of the lateral patella. Crepitus is noted. There is tenderness of the patella tendon, distal half of the …show more content…
Treatment plan includes therapy to the left knee twice a week for 4 weeks and a left knee patella tracking brace.
Based on the primary treating physician’s progress report by Dr. Steinhardt dated 01/19/16, the patient complained of foot and ankle pain and stated that it was worse now than it was prior surgery. His left knee pain is stronger as well. Physical examination revealed reduced range of motion at the left ankle in all ranges by 50% or greater with weakness. IW is unable to heel or toe walk. There is pain upon palpation at the medial/lateral ankle. Pain is strongest in the Achilles tendon and insertion of the posterior calcaneus. There is slight swelling of the left ankle. Minor’s sign is present. There is crepitus in left knee especially during range of motion study. Moderate limping gait was noted. MD noted that the patient has completed 4 postoperative rehabilitation therapy sessions with some improvement but needs additional sessions.
Current request is for 30 Lidoderm Patches 5%; and 30 Tablets of Tramadol Extended Release 100 mg between 1/26/2016 and
Based on the progress report by Dr. McSweeney dated 01/07/16, the patient had a left ankle scope on 12/17/15 and has just started PT. He reports left ankle pain rated as 3-4/10 and feels stiff. He has a pulling pain on the left posterior knee with grinding sensation. He is unable to kneel.
On examination of the left knee, there is tracking of the lateral patella. Crepitus is noted. There is tenderness of the patella tendon, distal half of the …show more content…
Treatment plan includes therapy to the left knee twice a week for 4 weeks and a left knee patella tracking brace.
Based on the primary treating physician’s progress report by Dr. Steinhardt dated 01/19/16, the patient complained of foot and ankle pain and stated that it was worse now than it was prior surgery. His left knee pain is stronger as well. Physical examination revealed reduced range of motion at the left ankle in all ranges by 50% or greater with weakness. IW is unable to heel or toe walk. There is pain upon palpation at the medial/lateral ankle. Pain is strongest in the Achilles tendon and insertion of the posterior calcaneus. There is slight swelling of the left ankle. Minor’s sign is present. There is crepitus in left knee especially during range of motion study. Moderate limping gait was noted. MD noted that the patient has completed 4 postoperative rehabilitation therapy sessions with some improvement but needs additional sessions.
Current request is for 30 Lidoderm Patches 5%; and 30 Tablets of Tramadol Extended Release 100 mg between 1/26/2016 and