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Western
Physical Therapy is conveniently located off the 405, 710 and 605 freeways,
and is only 15 minutes from downtown Los Angeles. A large free parking
lot, with handicap accessible parking is just steps from the HealthCare
Clinic entrance. For more information about your individual needs, please
call us at:
562.928.0121
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Patient Report
Sample
| April 27, 1999
RE: CURRENT FUNCTIONAL
STATUS REPORT ON (patient name A here) |
| Dear Dr. (name), |
| Mr/Ms patient A has
been seen at Western Physical Therapy for the past 2 weeks for treatment
of his left shoulder. |
Change in this patient's
functional status as a result of therapy intervention: |
|
activity
|
initial
status on 4/13/99
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present status as
of 4/27/99
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| overhead activity: |
unable to reach
> 90o
flexion |
able to reach
> 90o flexion |
| lifting objects: |
unable
to lift > 90o flexion |
able
to lift light objects to 120o
flexion |
| carrying objects: |
limited
with pain on exertion |
limited
with pain on exertion |
| objective
impairments of function: |
PT intervention: |
| 1. limited
strength of the left rotator cuff: 3-/5 external rotators, 3+/5 abductors
and supraspinatus; long head of biceps |
1. isometric
strengthening with contraction of cuff in mid-ranges |
2. limited left
shoulder AROM:
0-90o
flexion; 0-100 |
2. PROM
and flexibility exercises; strengthening of rotator cuff and scapulothoracic
stabilizers |
| 3. inflammation
of anterior and superior GHJ |
3. phonophoresis,
ice |
| The patient has
been able to tolerate slow progression of exercise program with intermittant
pain during active ROM with resistance, but decreased symptoms overall.
(Patient
A) has also been instructed to perform home exercises and tape to support
the left glenohumeral joint for added stability. The plan of care
is to continue therapy for 6 to 8 more visits with
long term functional
goal of upper extremity function of reaching, lifting and overhead
activity for daily functional objects with self management of symptoms. |
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