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
HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement many years ago by Dr. Dodd at the University of Miami. She has had multiple other surgical procedures as follows. A: She had bilateral foot surgery In the remote past. B: She had left hip surgery a year ago. C: She had right foot
Treatment plan includes diagnostic and therapeutic corticosteroid injection to the left bursa as IW may have trochanteric bursitis given the etiology of his symptoms.
Starting within four weeks of being sent to my ward on November 5th, 2017, Ms. Murakami had left total hip replacement (THR). Since the surgery, she has experienced subnormal recovery time, increased weakness, and lethargy; limiting mobility and weight-bearing exercises.
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.
The patient underwent irrigation and debridement of the right foot per operative report dated 11/11/13.
PHYSICAL EXAM: Wounds are healed. Calves are soft, nontender, nondistended. No pitting edema. Motion of the hip causes no pain.
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.
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 really, while she is walking. Overall, she is doing quite well.
Patient has a history of a myocardial infarction (MI, or also known as a heart attack) in 2004, she had a hip pinning in 2005, and a traumatic amputation of fingers on her left hand in 1974 from a lawnmower accident.
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
On examination of the left knee, the incisions are well healed. Range of motion is 0-135 degrees with
Examination on admission to the hospital showed marked tenderness over the right femoril vein and the long safenous vein from the groin to approximately midthigh. There was no redness or edema; homan sign was negative, and there were no obvious significant varicosities and no calf-tenderness.
Physical Therapy Case Report/Study At first glance, the concept of conducting a case study can seem rather intimidating due to the multitude of data and research that a clinical trial produces. Conveying this clinical information to one’s peers in a universal format that can be easy to read and understand may be just as painstaking if there is a lack of knowledge in the structure a case report must possess. In order to prevent confusion and promote quick and efficient reading, authors utilize a similar format to organize the information they present to their peers. Generally, case reports can be boiled down to the sections:
On 12/29/17 I met Ms. Becquette at the office of Dr. Saleh. She arrived ambulating with crutches. She had on an ankle brace and a full leg brace. The pin sites have all healed. X-rays done today showed that there is bone healing, the fractures have not fully healed yet, there is also some osteopenia, which we would expect from the dis- use of the bones. She can only bend her knee to 26 degrees, the ankle she cannot bend it is dropped and contracted, and she is able to wiggle her toes. The numbness she has had to the leg and foot is gone. The EMG has not been done yet because of Mom's schedule. She said she would call and make an appointment soon. Physical therapy is making some improvement. Dr. Saleh said he wants her to work really hard in therapy, he said it would be a last resort to go in and release the adhesions to the knee and the Achilles tendon for the ankle. Dr. Saleh said he feels she can work through this. She is allowed to bear weight as tolerated. The new brace has not arrived yet and is supposed to be in next week. We did address the attendant care and Mom was hesitant to decrease to 8 hours a day. Ms. Becquette will be going back to public school on 1/19/18. Physical therapy will continue even after her return to school.