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Medical Report Sample

Decent Essays
DOI: 5/26/2015. Patient is a year old male line services technician who sustained injury to his bilateral feet while he was walking down the airport ramp when he was hit from behind by a golf cart. Per OMNI, he was initially diagnosed with contusion/sprain of the bilateral feet. It was noted that his left foot pain has resolved but there is still pain on the right foot.
Per PT daily note dated 11/19/15, the IW has attended 19 sessions to the right foot/ankle.
Based on the latest medical report dated 11/23/15, the patient reports that his bilateral feet pain is over the ball of the foot. He has increased pain with the first step out of bed, right greater than the left. He has increased pain with pressure over the area. He also reports occasional numbness and tingling. There is pain with prolonged walking. Patient is going to PT. He is taking Advil occasionally.
On examination of the lower extremities, there is a well healed laceration over the right Achilles with some discomfort on
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Left ankle ROM shows dorsiflexion of 15 degrees and plantar flexion of 30 degrees.
Bilateral ankles inversion and eversion are decreased.
Impression includes bilateral foot plantar fasciitis and metatarsalgia.
Treatment plan includes medications as needed, home exercise and stretching, MRI of the right foot, continuation with PT, metatarsal pads, Voltaren gel massage and Advil.
On the statement of medical necessity on the C-4 form dated 12/16/15, bilateral foot is not at MMI and more therapy is needed to restore function and range of motion. Six additional weeks of therapy is anticipated to improve function and activities of daily living. The medication is g helping for pain but therapy is needed to restore range of motion and strength. A home program is important but not appropriate alternative to treatment. The claimant agrees to the proposed medical
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