Hyperteric Osteotomy Case

Satisfactory Essays
DOI: 4/29/2015. Patient is a 48-year-old female occupational therapist who sustained injury while engaged in an exercise with her patient. Per OMNI entry, patient has had several surgeries to her right hip on 02/02/16, 03/11/16 and 05/09/16. Patient is using crutches and is slated for hardware removal in 01/2017.
Per the medical report dated 10/17/16 by Dr. Muldoon, the patient has had extensive physical therapy and her gait has slowly improved. Her pain is very well controlled, although she has a deep, aching thigh pain. At this point, the osteotomy is now healed, but she has discomfort in her hip that may well be related to hardware sensitivities as it appears that IW does have a sensitivity to stainless steel or any other products with high nickel as is her plate construct.
On examination, the incision is mildly hypertrophic, but well healed. There is some loss of thigh girth. Range of motion of the hip is well balanced and pain free. She is tender to palpation on the deep thigh.
Of note, radiographs from previous visit in the office demonstrate no deterioration in her joint space as well as a healed subtrochanteric osteotomy with anterior plate and a lateral blade plate.
It was noted that continued physical therapy once a week for the next eight weeks is appropriate
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She also reports hip pain.
On examination, there is tenderness upon palpation over the greater trochanter. IW has a mild limp.
IW was diagnosed with status post osteotomy, right hip impingement and bursitis.
Attached is the panel QME report dated 12/18/15.
Requested from the provider’s office copies of procedure reports as well as PT notes; however, no reports were received prior to the submission of this request to PA.
Current request is for 1 Functional Rehabilitation Evaluation between 12/5/2016 and
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