DIAGNOSIS:
Status post left ankle ORIF ICD-10 S82.853
SUBJECTIVE:
The patient is a 61-year-old female, referred to physical therapy status post left ankle surgical repair due to fracture. The patient reports that, overall, her pain management has been good. Pain at its worst is 4/10. The pain averages at about a 2-3/10. The patient does report that most of her pain is in both of her knees, and also she has history of severe right heel pain. Since surgery, the patient has been using a wheelchair for most of her locomotion. However, lately the doctor has released her to put weight on her foot. She states that she has been walking about seven to 10 feet in her house, mainly just using countertops and furniture to get to and from the bathroom. She states that she does have a walker that she can use.
OBJECTIVE: …show more content…
Gait assessment demonstrates the patient could walk 40 feet with front-wheel walker with CAM boot on with only standby assistance. The patient did have difficulty during gait assessment when having to perform turning maneuvers due to knee pain. The patient's straight line walking was good. The patient's left ankle measured +2 degrees of dorsiflexion, 44 degrees of plantar flexion, 18 degrees of inversion, 18 degrees of eversion. The patient denied any adverse pain during the range of motion assessment. Manual muscle test to left ankle demonstrated 4-4+/5 strength. Again, the patient denied any adverse pain during exertion. Today's treatment consisted of evaluation x20 minutes, followed by therapy to exercise consisting of active assisted left ankle mobility activities in all planes, followed by strengthening exercises for dorsiflexion, plantar flexion, inversion, and eversion with red TheraBand x10 to 15 repetitions. The patient did express reproduction of discomfort with plantar flexion. However, her discomfort subsided shortly after stopping
Status post left ankle ORIF ICD-10 S82.853
SUBJECTIVE:
The patient is a 61-year-old female, referred to physical therapy status post left ankle surgical repair due to fracture. The patient reports that, overall, her pain management has been good. Pain at its worst is 4/10. The pain averages at about a 2-3/10. The patient does report that most of her pain is in both of her knees, and also she has history of severe right heel pain. Since surgery, the patient has been using a wheelchair for most of her locomotion. However, lately the doctor has released her to put weight on her foot. She states that she has been walking about seven to 10 feet in her house, mainly just using countertops and furniture to get to and from the bathroom. She states that she does have a walker that she can use.
OBJECTIVE: …show more content…
Gait assessment demonstrates the patient could walk 40 feet with front-wheel walker with CAM boot on with only standby assistance. The patient did have difficulty during gait assessment when having to perform turning maneuvers due to knee pain. The patient's straight line walking was good. The patient's left ankle measured +2 degrees of dorsiflexion, 44 degrees of plantar flexion, 18 degrees of inversion, 18 degrees of eversion. The patient denied any adverse pain during the range of motion assessment. Manual muscle test to left ankle demonstrated 4-4+/5 strength. Again, the patient denied any adverse pain during exertion. Today's treatment consisted of evaluation x20 minutes, followed by therapy to exercise consisting of active assisted left ankle mobility activities in all planes, followed by strengthening exercises for dorsiflexion, plantar flexion, inversion, and eversion with red TheraBand x10 to 15 repetitions. The patient did express reproduction of discomfort with plantar flexion. However, her discomfort subsided shortly after stopping