Mark “Hx” on the line before each statement that should be placed in the History portion of the Patient/Client Management Not

Mark “Hx” on the line before each statement that should be placed in the History portion of the Patient/Client Management Note. Patient: Rachacl F. Setting: Outpatient Orthopedic Clinic 1. 54 y/o & pt of Dr. Clare Milner 2. (+) tenderness to palpation over (B) long head of biceps tendon insertion & (A) supraspinatus muscle belly 3.

↓

(B) shoulder inf

&

post capsular mobility 4. Medical Dx: (B) shoulder adhesive capsulitis

s/p

@ shoulder open acromioplasty, distal clavide resection, resection of coracoacromial ligament, manipulation under anesthesia, & application of pain pump catheter on

10/05/15

5. Follows

100%

of 2 -step commands during eval. 6. Allergiest none. 7. Works as a medical biller for local hospital. Was indep ejob duties of typing at computer, answering phone, & carrying files up to

20=

8. – No formal strength testing of (B) shoulder 24 to surgical precautions per MD protocol. 9. Muscle Tone: WNL throughout (R) UE 10. (R) handed 11. Reported intermittent numbness/tingling in (B) UE in radial nn distribution preoperatively, but denies any neuro signs & symptoms post-operatively 12. Prior to surgery was indep c all functional mobility, BADLS, & IADIs, including driving 13. (” person responsible for household chores of cooking, cleaning. & laundry, but spouse is able to provide assistance in evenings prn until pt is able to complete activities 14. Enjoys bowling. playing horseshoes, & singing in her church choir 15. Seated bilat scapula retraction

⟸5

sec holds

cmax

tactile cues,

x10

reps PART I. Mark “Hx” on the line beforc each statement that should be placed in the History portion of the Patient/Client Management Note Patient: Rachael F. Setting: Outpatient Orthopedic Clinic 1. 54 ylo 9 pt of Dr. Clare Milner 2. (t) tenderness to paipation over (B) long head of biceps tendon insertion & (B) supraspinatus muscle belly 3. 4(A) shoulder inf & post capsular mobility 4. Medical Dx. (B) shoulder athesive capsulitis sp (B) shoulder open acromioplasty, distal clavicle resection, resection of coracoacromial ligament, manipulation under anesthesia, 8 application of pain pump catheter on toios/15 pain pump catheter on 10/05/15 5. Follows

100%

of 2 – step commands during eval. 6. Allergies: none: 7. Works as a medical biller for local hospital Was indep c job duties of typing at computer, answering phone, & catrying filer up to

20=

phone, & catrying files up to

20=

8. No formal strength tenting of (B) shoulder 2′ to surgical precautions per MD protocol. 9. Muscle Tone: WNL throughout (B) UE 10. (B) handed 11. Reported intermittent numbiess/tingling in (A) UL in radial nn distribution preoperatively, but denies any neuro signs & symptoms post-peratively 12. Prior to surgery was indep z all functional mobility, BADLS, s. IADLs, including driving. 13.

1 

” 

person responsible for houchold chores of cooking cleaning 8 laundty, but spoute is able to provide assistance in evenings prn until pt is able to complete Activitiei 14 Enjoys bowling, playing honestwoes, & singing in her church choir 15. Seated bilat seapula retraction 25 sec holds 2 max tactile cues,

x10

repy