Physical Therapy Evaluation Medical Transcription Sample Reports

Dear Dr. Doe:

We saw the patient today for an initial evaluation with the following results:

SUBJECTIVE FINDINGS:  This patient is a (XX)-year-old white female with pain in her lumbosacral spine, extending into her buttocks bilaterally.  She describes the pain as being sharp and sometimes intense.  She states it diminishes to an achy feeling.  She rates its intensity at 10/10 at its worst.  Normally, she states it is 6-7/10.  She describes the pain as being ever-present, varying in intensity, increasing with activities and decreasing with rest.  She is using pain medications currently and is able to sleep through the night.

HISTORY:  This patient initially injured her back by catching a falling TV.  She had immediate pain, it was disabling.  The pain was resolved with occasional recurrence.  She sought intervention last year from doctors, who diagnosed degenerative disc disease and arthritis.  She had a course of physical therapy with some resolution, but recurrence of pain occurred in September secondary to bending over while washing her hands.  She was referred here.

OBJECTIVE FINDINGS:
Observation:  This patient appears as a normally developed white female of stated age.  She reports moving with forward flexed posture and an occasional antalgic gait on the right when the pain is increasing.  She currently postures and moves normally.
Palpation:  Positive over L4 and L5 and paravertebral muscles at that same level.
Range of motion:  Forward flexion 35 degrees with pain at the end of range.  Right side bending 30 degrees with pain at the end of range.  Left side bending 35 degrees.  Extension 0 degree with pain at the end of range.
Resisted motion:  Positive in all directions.
DTRs:  Hyperreflexive bilaterally.
Lasègue’s sign:  Positive at 25 degrees bilaterally.
Cram test:  Positive at 25 degrees bilaterally.
Cervical range of motion:
1.  Right side bending:  Within normal limits, painful.
2.  Left side bending:  Within normal limits.
3.  Forward flexion:  45 degrees with pain at the end of range.
4.  Extension:  Within normal limits.
Radiculopathy:  Positive with pain down the left arm and occasional tingling and numbness.

TREATMENT PLAN:  We would like to see the patient three times per week to initiate exercises and modalities to decrease pain and increase range of motion and function.

GOALS:  The purpose of physical therapy intervention is to:
1.  Increase range of motion to normal limits.
2.  Decrease pain to zero.
3.  Increase strength and function to normal.

Thank you for having us see this patient.

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Dear Dr. Doe:

We saw the patient today for an initial elevation with the following results.

SUBJECTIVE FINDINGS:  This patient is a (XX)-year-old female with pain in her cervical spine.  She states that the pain extends over the entire posterior neck and into the right shoulder, including the upper trapezius.  She rates that at a level of 7-8 on a scale of 10 currently.  She states that at its least it is 2-3 on a scale of 10.  The patient is using cervical collar with good results.  She also uses ibuprofen at night.

HISTORY:  This patient was involved in a MVA 10 years ago resulting in a fracture of C6.  She had manipulation approximately 5 years ago resulting in pain times approximately 5 months.  She had neck pain develop again approximately 2 years ago resulting in bilateral shoulder surgery.  The pain has remained the same, although the numbness is better for approximately one year.  She currently has complaints of a radial distribution into her right hand, which caused her to be concerned enough to seek intervention from Dr. Doe.  The patient was then referred here.

OBJECTIVE FINDINGS:

Observation:  This patient is a normally developed female of stated age.  She gaits normally without apparent guarding or splinting.

Palpation:  Positive over the right upper trapezius.

Range of motion:  Right rotation is 50 degrees, left rotation is 45 degrees, right side bending 30 degrees with pain at the end of range, left side bending 30 degrees, forward flexion 35 degrees, and extension 25 degrees.

Resisted motion:  Negative.

Radiculopathy:  Positive in the right shoulder extending down her right hand into her thumb and digit 2 and 3.

Sensation:  Some decreased sensation over the right hand to pinprick, particularly over the radial digits.

TREATMENT PLAN:  We would like to see the patient three times per week as per instructions for cervical traction and exercises.

GOALS:  The purpose of physical therapy intervention is to:

1.  Increase range of motion to normal limits.

2.  Increase pain-free function to normal.

3.  Decrease pain generally to zero.


Thank you for having us to see this patient.

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Dear Dr. Doe:

We saw the patient today for an initial evaluation with the following results:

SUBJECTIVE FINDINGS:  This patient is a (XX)-year-old white female with pain in her lumbosacral spine.  The pain is described as being persistent and ever-present in the lower back and hips.  She states that the pain varies with prolonged positioning such as sitting and lying down.  She has increased pain with twisting motion.  She rates the pain at 3/10 and at least 8-9/10 at its worst.  She states that the frequency of harsh pain is weekly to biweekly.  The patient is currently using a muscle relaxant pain medication p.r.n. from Dr. Smith.

HISTORY:  The patient states that her pain occurred 5 years ago with an insidious onset and an unknown etiology.  She has been to multiple doctors, which include x-rays and an MRI, with no diagnosis.  She had an MRI last month and sought intervention from Dr. Jane Doe who diagnosed spondylolisthesis.  She was sent to physical therapy, back school, which occurred and has been referred now for an exercise program.

OBJECTIVE FINDINGS:
Observation:  This patient appears as a normally developed white female of stated age.  She gaits and moves normally.  She reports slow transitions from sitting to standing, and she also states that when the pain is bad, she has an antalgic gait with the first few steps.
Palpation:  Positive at L4-5 and paravertebral muscles surrounding that area.
Range of motion:  Within normal limits, without pain.
Resisted motion:  Positive in right side bending.
Muscle strength:  5/5 in the lower extremities.
Lasègue’s sign:  Negative.
Cram test:  Negative.

TREATMENT PLAN:  We would like to see the patient weekly to initiate exercises to include stretching and strengthening to the cord musculature to stabilize the spondylolisthesis.

GOALS:  The purpose of physical therapy intervention is to:
1.  Increase the strength and function of the torso.
2.  Decrease pain to zero.
3.  Increase function to normal.

Thank you for having us see this patient.


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Dear Dr. Doe:

We saw the patient today for an initial evaluation with the following results.

SUBJECTIVE FINDINGS:  This patient is a (XX)-year-old male with pain in his left shoulder, mainly the posterior aspect.  The pain is described as being a sharp pain, particularly with lifting objects.  He has zero pain at rest.  He rates the pain at a level of 6-7 on a scale of 10 at its worst.  The patient currently is limited in his weight by the doctor to 10 pounds.  He is using ibuprofen three times per day with good results.  He further states that there is increased stiffness in the morning.

HISTORY:  This patient was moving cycles and lifting motorcycles.  When he was lifting his motorcycle, he lost his grip with the weight falling slowly on his left arm.  The patient had immediate severe pain.  He sought intervention one week later hoping that it would resolve.  He went to the emergency room.  The pain increased over a period of time, so the patient sought intervention from Dr. Doe.  Dr. Doe referred the patient here.

OBJECTIVE FINDINGS:
Observation:  This patient appears a normally developed male of stated age.  He gaits and moves without posturing or splinting.
Palpation:  Positive over the posterior aspect of his left shoulder.
Range of motion:  Within normal limits with pain at 90 degrees of abduction.
Resisted motion:  Positive in all motions except extension.
Muscle strength:  –4/5 in all motions limited by pain.
Radiculopathy:  Negative.
Grip strength:  Right 90 pounds, left 45 pounds.

TREATMENT PLAN:  We would like to see this patient three times per week to initiate exercises and modalities to decrease pain and increase strength and function.

GOALS:  The purpose of physical therapy intervention is to:
1.  Decrease pain to zero.
2.  Increase pain-free range of motion to within normal limits.
3.  Increase strength to 5/5.

Thank you for having us see this patient.

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HISTORY:  The patient is a (XX)-year-old white female who, last month, fell on her left elbow sustaining a left distal humerus fracture.  The patient states approximately the following day she had surgery to stabilize the fracture.  The patient was unsure if the surgery performed was for plates and screws.
 
PAST MEDICAL HISTORY:  The patient fractured her left wrist approximately a year ago.
 
SUBJECTIVE FINDINGS:  The patient reports left elbow pain, currently 8-1/2 to 10, at best 8-1/2 to 10, and at worst 10/10.  The patient states she is taking her pain medications, which provide minimal relief.  The patient reports she does have numbness in the left upper extremity, along the ulnar nerve distribution.  The patient states she does use some ice or heat; it provides minimal relief.  The patient is right-hand dominant.
 
OBJECTIVE FINDINGS:  Left elbow AROM 35-120 degrees.  Left elbow PROM 30-135 degrees.  Left shoulder AROM within normal limits.  Left wrist AROM within functional limits.  Left elbow strength 3-/5.  Left shoulder strength grossly 4/5.  Left wrist strength grossly 4/5.  Left grip strength is 30 pounds.  Right grip strength is 55 pounds.  Palpation:  The patient is tender to palpation in the posterolateral aspect of the left elbow.  The incision is healed.  No signs of infection.  No swelling in the left elbow, no bruising.
 
GOALS:
1.  Increase left elbow AROM and PROM to within normal limits.
2.  Increase left elbow strength to within normal limits.
3.  Eliminate pain.
4.  Independent with home exercise program.
5.  Return function to normal.
 
TREATMENT PLAN:  We would like to see the patient three times a week to initiate and advance range of motion, stretching and strengthening program to left elbow, may use modalities as needed for pain control.




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