Health Assessment Physical Assessment Documentation Form Date: __3/3/16 Patient Information Patient Initials | LD | Age | 30 | Sex | Female | General Survey Does patient appear to be their stated age? | Yes | Level of consciousness | Alert and Oriented x3 | Skin color | Caucasain | Nutritional status | No malnurishment noted, pt she eats three meals a day | Posture and position | Patient maintains good posture and position | Obvious physical deformities | No physical deformities noted | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet,
As my mother continued to recover from her injured arm, the occupational therapist in the hospital was especially attentive to her needs. She was always there to help with anything my mother needed, and assisted her in regaining the full use of her arm. She used different modalities to increase my mother’s arm strength, range of motion, and reduced her pain. Her therapy has included gentle stretching excerices, massage, and excerices with weights. The Occupational Therapist also given her instructions to do certain exercises at home, which I was able to assist
Student’s Name: Sofia Damos Date: 06/16-06/17 Client’s initials: P. N. Age: 55 years old Medical Diagnosis: Client was diagnosed with a fractured right tibia bone, and fractured right radial bone. Client has diabetes mellitus type one. Client has history of hypertension and was admitted with chest pain following accident. The client fell off her bicycle while walking her dog.
Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.
TOTAL RIGHT HIP ARTHROPLASTY OBSERVATION 2 Total Right Hip Arthroplasty Observation On April 11, 2014, I had the privilege of direct observation of a patient’s orthopedic surgery, from the pre-operative to post-operative setting. The patient with the initials N.R, which we will call Mrs. R, arrived to the hospital just prior to 6:30a.m. As the name implies, Mrs. R was a female patient, 76 years old with an admitting diagnosis of right hip osteoarthritis. Due to arthritis in her hip, Mrs. R’s ability to perform daily activities and participate in hobbies such as dancing has been extremely compromised over the last 2 years. The overall goal of Mrs. R’s surgery
DOI: 09/18/2012. Patient is a 59-year-old male truck driver who sustained injury to his head, left eye, ribs, lungs, shoulder, and back when he lost balance and fell while he was removing tarp at an ecology sample area. Per OMNI entry, he was initially diagnosed with punctured lung and
The patient underwent irrigation and debridement of the right foot per operative report dated 11/11/13.
Per AME dated 09/09/2013 by Dr. Luciano, the patient has reached Maximum Medical Improvement from an orthopedic standpoint and the patient has a total of 42% whole person impairment.
DOI: 3/22/2012. Patient is a 57-year-old female office coordinator who incurred a work-related injury due to repetitive computer business. As per OMNI, the patient was seen and examined for left elbow radial tunnel syndrome. He is status post left elbow surgeries on 01/16/13, 07/11/14 and 2/23/2015. He is also
OI: 11/22/2009. Patient is a 46-year-old female certified nursing assistant who sustained a work-related injury to her low back while helping move/lift a patient. Per OMNI, the patient is diagnosed with status post lumbar laminectomy surgery on 07/26/10, lumbar degenerative disc disease, and lumbar radiculopathy. She was deemed to have reached permanent and stationary status by PQME Dr. Well last 12/01/11.
IMAGING: X-ray of the pelvis shows a well aligned, hemiarthroplasty bipolar hip prosthesis. IMPRESSION: Two and a half to three weeks out left hemiarthroplasty hip, doing well. PLAN: Continue total hip precautions. She is only on a baby aspirin now, so think I would like to continue her on a regular aspirin for at least a few more weeks.
HISTORY OF PRESENT ILLNESS: Katherine is here for an almost three weeks out followup left hip hemiarthroplasty. She is doing very well. She is actually at home, amazingly, already. She has complaints of mild groin pain at night that occasionally wakes her up. No pain
DOI: 12/14/2015. Patient is a 36- year-old male FIELD TECHNICIAN II who sustained a work related injury when he LOST FOOTING & FELL while WORKING ON SLIPPERY BUILDING LADDER. The patient was subsequently diagnosed with right epicondylitis. X-ray, 2 views dated 1/29/16 (no official report) revealed that there is no
PHYSICAL EXAM: Cast is intact. She is walking on it. Neurovascularly intact. Calves are soft and nontender.
DOI: 5/6/2012. The patient is a 34-year-old female registered nurse who sustained a work-related injury when she felt a pop in her left shoulder due to turning a patient who weighed 250 pounds in a hospital bed. As per OMNI, the patient is status post left shoulder surgery on 10/19/12.