Sample Medical Recommendations

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I met Mr. Eigner at the office of Dr. Taha. Mr. Eigner reports he is not taking any pain medications at this time. He reports he has a jolting shooting pain to the right and left legs only occasionally. He denied any pain to his right forearm. X-rays taken showed good alignment and healing of the fracture. The incisions are all healed except for a couple small spots on the right ankle. There is some swelling to the right ankle which Dr. Taha said is to be expected. The range of motion to the left ankle and toes was good. The range of motion to the right stores was limited. Dr. Taha said there is scar tissue at times from this type of repair and he would like physical therapy to start working on that. He is still going to be non-weight bearing for another 6 to 8 weeks on the right leg. He is now allowed full weight bearing as tolerated to the left leg. Dr. Taha ordered a rolling scooter to aid with ambulation and stop using the wheelchair. I have contacted Reverence physical therapy and faxed the new orders so the service can begin. I will process the rolled scooter with directions from the adjuster. The attendant care and replacement services will continue through to the next appointment.

12/24/15 Progress Report describes that the patient has right knee pain. The pain is frequent. It is aching and burning in quality. The current pain level is 0/10 and worst pain is 4/10. Bending, squatting, walking, weight bearing, changing clothes and ROM aggravate the pain. Rest, ice,

Physical therapy saw the patient, and the result of the examination are as follows; 6/10 left knee pain at rest and during activity (0 no pain, 10 worst pain), manual muscle testing for both upper and lower extremities were 4/5 except left knee flexion/extension 3+/5 due to pain, sensation on both UE/LE were intact to light touch, Stephen requires a moderate assistance of one person for both functional mobility and gait activity. He uses a front wheeled walker up to 35 feet due to decreased balance and antalgic gait from the left knee

Based on the progress report dated 08/23/16, the patient complains left knee pain upon walking. Discomfort was described as aching, tingling, intense, severe, continuous, pain, discomfort, increasing with movement and varying with activity. Pain is rated as 5/10 without medications and 4/10 with medications.

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Based on the orthopedic consultation report dated 03/04/16 by Dr. Strudwick, the patient reports that his symptoms have returned and he has pain at night with elevation, pushing, pulling, reaching and heavy lifting at shoulder level and above.

Examination of the right knee reveals pain to palpation over the iliotibial band with intermittent clicking over the lateral femoral epicondyle. He continues to exhibit an altered gait without a gait aid. Biomechanics of gait are altered in the right lower

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Offender comes in today in followup off left thumb pain. She was in a car accident in 11/2015 and jammed her thumb against the airbag. Ever since she has had pain around her MCP joint. She was evaluated by an orthopedist in the past and surgical intervention was recommended. She received a Kenalog injection last year and got good relief. Since the pain was acting up, she was again injected left thumb on 09/20. She reports at least 50% symptom relief. She denies any numbness, tingling in the joint. She is currently on Mobic twice daily, but in addition has also been taking ibuprofen throughout the day. She was prescribed ranitidine, which has helped with heartburn symptoms and would like to continue it. For the past two weeks, she has been getting headaches. She does not have a previous history of migraine headaches. She has some discomfort in her right ear, sore throat which lasted 24 hours. She denies any fever, cough, nasal or head congestion. She also

Diagnoses are cervical radiculopathy, right shoulder pain, nondisplaced fracture of the greater tuberosity of the right humerus and right shoulder bursitis. He has reached maximal recovery for his right shoulder. MD is concerned that the elbow and hand pain are related more to his neck as he has a history of cervical radiculopathy and his symptoms are more of tightness than pain that can be localized. He has had epidural injections in the past for left sided radiculopathy. An updated MRI is requested. If there are right-sided findings, he will be sent for possible injection for the upper extremity pain. Otherwise, he will be sent for a second opinion for his continued

Based on the progress report date03/16/16, the patient has been managed conservatively with PT and has continued to experience discomfort. His pain has migrated from primarily thoracic to more localized lumbar pain.

He elevates foot, rest it, applies ice pack, and takes pain medication to help alleviate pain. Patient is currently taking Norco. Patient is not under any form of therapy. Patient walks with a limp favoring the left leg. There is noted tenderness on the medial aspect of the left ankle, and swelling on the lateral aspect of the ankle. Patient’s last x-ray was done a year ago and revealed hard palpable mass on the rear foot at talonavicular joint which is potentially a screw placed by previous surgeon. There is 6/10 pain noted at the anterior talofibular ligament and calcaneofibular ligament. Pain is increased with plantarflexion and inversion of foot/ankle. The peroneal tendon is weak and painful along the lateral malleolus. The palpable pain is rated as 9/10. Pain increases against resistance to the peroneal muscle. There is pain noted at the lateral shoulder of the ankle mortis. Muscle testing showed 3/5 on the left ankle evertors.

The physician will go on vacation after today and he will be back for cases on 2/16/2017. Please review and advise.