SUBJECTIVE FINDINGS: This patient is a (XX)-year-old Hispanic female with pain in her right buttocks and hip, down into her leg and to her toe. She complains of the toes becoming numb, in the last three digits. The patient states that the intensity of the pain is 6 on a scale of 10 usually and has been as much as 10 on a scale of 10. She states that the pain is ever present and varies in intensity. She is using Tylenol with Codeine currently with a muscle relaxant.
OBJECTIVE FINDINGS:
Observation: This patient appears a normally developed Hispanic female, her stated age. She gaits and moves normally with the exception of an antalgic gait on the right.
Palpation: Positive in the right buttocks.
Range of Motion: Forward flexion, 95 degrees with pain at the end of range. Right side bending, 30 degrees with pain at the end of range. Left side bending, within normal limits.
Extension, 0 degree with immediate pain. Painful stimuli on the right side.
Resisted Motion: Positive with left side bending.
Muscle Strength: 4/5 in the right ankle and toe, 5/5 in all other areas.
Radiculopathy: Positive with pain in the posterior leg from the buttocks to the foot and numbness in the last three toes.
Sensation: Decreased to pinprick over the right lateral calf. Lasegue’s sign positive on the right at 70 degrees. Cram test positive at the same range.
TREATMENT PLAN: We would like to see the patient daily x10 days as prescribed for hot moist pack, ultrasound, and intermittent pelvic traction. We would also like to add exercises to the low back into extension at the appropriate interval.
Sample #2
HISTORY: The patient is a (XX)-year-old Asian male who sustained a C4-C5 crush fracture as well as a fracture of C3 and C6. The patient states that since then he has had right-sided paralysis but has been functional. The patient states in the last six months he has noticed a decline in his function, especially in his right wrist and hand, thus prompting the patient to seek medical intervention. The patient is referred to physical therapy for right hand weakness for PT evaluation and a home program to increase strength and function of right hand and wrist.
SUBJECTIVE FINDINGS: The patient denies any pain in the right upper extremity or right lower extremity. The patient states he is ambidextrous. The patient states his ambulation has declined as well and has noticed increase in loss of balance; although, the patient has denied any falls. The patient does not use an assistive device, nor does he use an AFO on that right ankle.
OBJECTIVE FINDINGS: The patient ambulates with an abnormal gait pattern. The patient presented with a right toe drag, decreased right knee flexion, decreased right hip flexion, and increase in trunk swing. The cervical range of motion was within normal limits for all movements, except bilateral side bending, within functional limits. Right shoulder AROM: Flexion 0-160 degrees, abduction 0-160 degrees, external rotation 0-70 degrees, internal rotation within normal limits. Right shoulder PROM: Flexion 0-180 degrees, abduction 0-180 degrees, external rotation 0-80 degrees, and internal rotation within normal limits. Right shoulder strength: Flexion 4/5, abduction 4-/5, right biceps strength 4-/5, and triceps 3+/5. Right grip strength was 25 pounds and left grip strength was 60 pounds. Right wrist and finger range of motion: Passive range of motion within normal limits, active range of motion limited, yet functional. The patient did not present with a right hand contracture or finger contracture. Right lower extremity range of motion: Right hip not tested, is limited, although is functional. The patient is lacking active knee extension range, approximately lacking 20-30 degrees. Right ankle strength: Dorsiflexion 3-/5 and plantarflexion 5/5. Muscle tones: The patient was noted to have multiple beats of clonus in right ankle, did not test tone in upper extremity. Palpation negative.
TREATMENT PLAN: This patient was seen for a one-time visit only for evaluation and treatment. The patient was evaluated as per above. Treatment was provided as well. The patient was given a home exercise program, including right upper extremity and lower extremity strengthening exercises, as well as stretching exercises for the right shoulder. The patient demonstrated understanding of the exercising and was able to demonstrate them accurately. The patient was also given yellow TheraBand to complete these exercises. The patient was instructed to perform these exercises one to two times daily to increase his strength and range of motion. Further physical therapy intervention is not indicated at this time, as the patient is independent with home exercise program.
