Left Knee Case Summary
DOI: 1/18/2016. Patient is a 31-year-old female who sustained injury when she had a fall after slipping on the wet mat. . Per OMNI, he was initially diagnosed with
Per the PT daily treatment note dated 06/14/16, the patient has had 12 sessions. Plan is for aquatic therapy. PT will be place on hold.
Per the medical report dated 06/02/16, the patient presented for evaluation of her left knee. She has responded poorly to a cortisone injection.
Based on the progress report dated 06/21/16, the patient complains of bilateral lower back and radiating left thigh pain. She also has left knee and ankle region pain and swelling. Pain is achy in character, mostly over the lumbar spine and left hip, and proximal portion of the left thigh. It is also stabbing. However, the lower leg is mostly pins and needles, associated with swelling on the left side. Pain …show more content…
Range of motion reveals restrictions with extension and left side bending, with an end-range pain. Forward flexion is mildly restricted. Hip flexors are slightly weak on the left side. Sensation is intact overall except lower portion of the left leg to light touch and pinprick. She is able to toe and heel walk with a slight unsteady gait. Lower extremity edema is noted, more on the left side than the right side. Impression is chronic low back and radiating left thigh/hip pain, likely multifactorial in origin including lumbosacral spondylosis with mostly some facet joint disease and increased lumbar lordosis, as well as evidence of degenerative disc disease.
Lumbar lordosis is increased.
Recommendation was made for weight reduction, home exercise program, and daily cardiovascular exercising.
Requested verification from the provider’s office on the IW’s height and weight; however, no callback/report was received prior to the submission of this request to
Per the PT daily treatment note dated 06/14/16, the patient has had 12 sessions. Plan is for aquatic therapy. PT will be place on hold.
Per the medical report dated 06/02/16, the patient presented for evaluation of her left knee. She has responded poorly to a cortisone injection.
Based on the progress report dated 06/21/16, the patient complains of bilateral lower back and radiating left thigh pain. She also has left knee and ankle region pain and swelling. Pain is achy in character, mostly over the lumbar spine and left hip, and proximal portion of the left thigh. It is also stabbing. However, the lower leg is mostly pins and needles, associated with swelling on the left side. Pain …show more content…
Range of motion reveals restrictions with extension and left side bending, with an end-range pain. Forward flexion is mildly restricted. Hip flexors are slightly weak on the left side. Sensation is intact overall except lower portion of the left leg to light touch and pinprick. She is able to toe and heel walk with a slight unsteady gait. Lower extremity edema is noted, more on the left side than the right side. Impression is chronic low back and radiating left thigh/hip pain, likely multifactorial in origin including lumbosacral spondylosis with mostly some facet joint disease and increased lumbar lordosis, as well as evidence of degenerative disc disease.
Lumbar lordosis is increased.
Recommendation was made for weight reduction, home exercise program, and daily cardiovascular exercising.
Requested verification from the provider’s office on the IW’s height and weight; however, no callback/report was received prior to the submission of this request to