DOI: 5/28/2012. Patient is a 64-year-old female home attendant who sustained injury when a client put her motorized wheelchair in reverse and it ran over her right foot, pushing her up against the wall. Per OMNI, she underwent a right knee arthroscopy with partial medial and lateral meniscectomy, chondroplasty, synovectomy and joint debridement on 03/18/13.
Based on the progress report dated 03/03/16, the patient is currently on PT 1-2 times per week. He complains of on and off lower back pain, on and off right knee pain with some improvement and right ankle pain and occasional swelling upon prolonged standing and walking. Patient has difficulty with bending, prolonged standing and walking.
On examination of the lumbar spine, flexion and extension is restricted by 10/10 degrees. …show more content…
On MG-2 form dated 03/07/16, the patient has lower back pain and stiffness and on gradual improvement with pain reduced to 7/10 on pain scale. Patient has lower back stiffness. Pain is gradually reduced and improving, with occasional radiating pain into both legs. Multiple trigger points are noted at the mid-thoracic to upper lumbar paraspinal muscles.
Lumbar spine range of motion (ROM) is about 20% improved but some trigger point at lumbar paraspinal is noted. Straight leg raise (SLR) remains positive at 50 degrees on the left side. Lumbar spine flexion/extension is restricted by 20/20 degrees. Therapeutic exercises will help for muscles to be strong and flexible. It will also help to increase range of motion (ROM) and promote circulation to enhance soft tissue to relive. Patient has delayed recovery but recommended to resume therapy treatment to reduce pain to 2/10.
Because of severe pain radiating into both legs, PT is recommended 2 times a week per week and pain management evaluation to meet the goal by reducing pain and symptoms to near intensity to 2/10 on pain
Based on the progress report dated 03/03/16, the patient is currently on PT 1-2 times per week. He complains of on and off lower back pain, on and off right knee pain with some improvement and right ankle pain and occasional swelling upon prolonged standing and walking. Patient has difficulty with bending, prolonged standing and walking.
On examination of the lumbar spine, flexion and extension is restricted by 10/10 degrees. …show more content…
On MG-2 form dated 03/07/16, the patient has lower back pain and stiffness and on gradual improvement with pain reduced to 7/10 on pain scale. Patient has lower back stiffness. Pain is gradually reduced and improving, with occasional radiating pain into both legs. Multiple trigger points are noted at the mid-thoracic to upper lumbar paraspinal muscles.
Lumbar spine range of motion (ROM) is about 20% improved but some trigger point at lumbar paraspinal is noted. Straight leg raise (SLR) remains positive at 50 degrees on the left side. Lumbar spine flexion/extension is restricted by 20/20 degrees. Therapeutic exercises will help for muscles to be strong and flexible. It will also help to increase range of motion (ROM) and promote circulation to enhance soft tissue to relive. Patient has delayed recovery but recommended to resume therapy treatment to reduce pain to 2/10.
Because of severe pain radiating into both legs, PT is recommended 2 times a week per week and pain management evaluation to meet the goal by reducing pain and symptoms to near intensity to 2/10 on pain