Listed below are statements that belong in the History part of a Patient/Client Management Note

Listed below are statements that belong in the History part of a Patient/Client Management Note. Below the History statements are headings used in the History section of the note. Enter the letter of the appropriate heading in the blank preceding each stafement. Headings may be used more than once in this exercise. Patient: Dornie

C

Setting: Outpatient Orthopedic clinic 1. Reports he is modified indep ₹ BADls द we M AD cqaipment 2. Patient of Dr. Ben Lemon 3. Worelumbosacral orthosis po surgery too a fete whs’ sy wised wheeled walker for amb is weaning himself from whected walker to no demice 4. clo loss of batance cchange of dirextion 5. (R) handed 6. Currently anable to carry or lift grocences of hwotchold items greater that let: 7. Used external bone stimulator p surgery as mo per MD urders 8. Lives espouse 9. Hx of HTN se hypercholesteroletrita 10. 68 ylo Gabcasian b 82 PARTIII Documenting the Examination 11. Denies any new onset numbnessitingling &s nearo signs & symptoms into l.k since surgery c exception of long-standing bilat periptheral neuropathy plantar surfice of feet 12. Self-reported long-standing hx of

1.BP

e progressive nutele weiknees & onset of radicular signs & symptoms into (1) LE beginning 3 yrs ago 13. Denies

hx

of falls 14. Owns equipment of tall whecled walker. NDthip kat 15. Retired from aerospace engincering firm 16. Current signs & symptoms

d

in severity c rest 16. Current signs & symptoms 4 in severity c rest 17. Takes 1 med for BP & 1 for cholesterol dallyi cannot recall med names 18. Enjoys playing golf, hilking s racquetball 19. Presents for skilled OP PT eval on 05/08/15 20. sip (L) THA 2 yrs ago, 2+ to

OA

21. Lives in 1-thoor ranch-style house csteps to eater from garaige, I step from front door shandrail, or

8+4

steps to enter from backyard entrance c I handrail 22. Currently unable to excruse by walking & working out at local gym as Pr was doing up wntil 6 mo ā surgery 23. Denies tobacco & alcohol abuse, but does “like te have a beet ह the neighbothood guys at conkouts once in awhile during the summer” 24. c/o f “feeling of weakness” & fatigue in (C) greater than (R) IE c prolonged standing & ambulation 25. Current signs & symptoms worse c standing or amb greater than 3 min at a time 26. sip weheduled L3-4 & LA-5 discectomy & post spinal fusion on 01/18/15 27. Reports inability to amb greater than

300 

′

at a time due to pain for 6 mo prior to surgery 28. clo 1/10 generalized lumbar spine pain at present time at rest 29. clo

$

generalized activity tolerance versus prior level of function a initial onset for s/s 3 yrs ago; fects he is at 50 the of his prior level of function 30. Reports no imaging completed since surgery A. Demographics B. Current Condition(s)/Chief Concerns C. Prior & Current Level of Function D. 14 Goals E. Social Hx 1. Fmployment Status 6. Physical Environment & Avathable Resource H. General Health Status L. Social/Health Habits 1. Growth & Development K. Family Health Hx L. Medi M. Review of Syntems N. Other Clinke thiagnostic Teth