DIAGNOSIS:
Left tibial fibular fracture.
STATUS AT TIME OF EVALUATION AND DATE:
Physical therapy evaluation on 6/25/2015. The patient is a 56-year-old female referred to physical therapy status post traumatic injury to her left lower extremity, status post surgical repair and fixation. Date of injury 2/25/2015. Date of first surgery 2/25/2015. The patient reports she that required a second surgery and thought the date was 3/11/2015. The patient reports that after surgery she was immobilized and used assistive device/crutches for three months without any physical therapy.
ASSESSMENT:
Initial assessment demonstrated impairments of pain, inflammation, chronic swelling, decreased joint soft tissue mobility left ankle, along with decreased…show more content… The patient subjectively reported that her pain and swelling have been elevated and more chronic lately. She expressed she was very frustrated with her recovery and did not feel that JAMES NEEL, M.D. was listening to her. She reports most of her pain is located along the lateral aspect of her ankle. Modalities that were applied consisted of interferential E-STIM for pain and swelling reduction, Effleurage massage, and general soft tissue and passive range of motion activities along with gentle exercises. The patient's recovery with decreased swelling and pain did not progress as anticipated. At the time of the last visit, she had not achieved any of her anticipated goals. The patient continued to have chronic swelling and pain in her ankle and foot and her antalgic gait pattern continued to persist and sometimes be worse. The patient was not using any assistive device at time of last visit. The patient expressed that she felt that a second opinion needed to be done at that time. The physical therapy office contacted the case manager Denise Dover to give her a status report on the patient's condition. Denise stated at that time was going to put a request into have the patient referred for a second opinion. At this time, the patient has received a second opinion and a second surgery was performed. The patient's original plan of care with Dr. Neel' surgery has been discontinued at this time. A new evaluation was performed by another physical therapist in our clinic. The patient is receiving her physical therapy to recover from surgery performed by PAT D DO,