PRIOR LEVEL OF FUNCTION
Prior to the current exacerbation of the illness, the patient needed no assistance (was independent) with basic activities of daily living (BADLs) including household mobility. IND WITH GETTING IN/OUT OF HOUSE, IND WITH TRANSFERS, GROOMING, BATHING, LAUNDRY, SHOPPING, TRANSPORTATION.
PAIN
LOWER BACK AT 4/10; WORST WITH COLD/RAINY WEATHER, WEIGHT BEARING, TRANSFERS; BETTER WITH REST, MEDICATION, DIVERSION
THERAPEUTIC EXERCISES
SKILLED PT REASSESSMENT COMPLETED. PATIENT PERFORMED/INSTRUCTED IN HOME EXERCISES PROGRAM.
Gait Intervention
THERAPIST INSTRUCTED PATIENT ON KEEPING AN ERECT/ UPRIGHT POSTURE DURING GAIT , ON THE PROPER SEQUENCING WITH THE 2WW, SLOWING PACE DURING TURNS AND DURING TRANSITIONS FROM DIFFERENT SURFACES IN ORDER TO IMPROVE OVERALL GAIT INDEPENDENCE AND BALANCE.
Reassessment
SUBJECTIVE
PATIENT STATED HE IS GLAD WITH HIS OVERALL PROGRESS, HOWEVER STILL GETS TIRED EASILY.
MMT
GROSS MUSCLE STRENGTH IN RIGHT HIP 3+/5 LEFT HIP 3+/5 IN RIGHT KNEE 3+/5 LEFT KNEE 3+/5 IN RIGHT ANKLE 4/5 LEFT ANKLE 4/5
example text
Transfers Intervnetion
Therapist instructed patient to scoot to the edge of the chair and place both feet at shoulder width, to place feet apart in order to maintain center of mass within base of support, to use bilateral elbow extension to push from arm rests to transfer from sitting to standing.
Balance Intervention
Dynamic Standing Balance: At the instruction of the therapist, patient performed dynamic standing balance exercise by standing on an even surface while maintaining feet at shoulder width. During the dynamic balance exercise, the therapist instructed the patient to perform reaching tasks designed to elicit righting reactions in order to improve balance and on sensory integration and resolution of sensory conflict. The exercise was performed for 10 repetitions.
Goals Pain
Patient will improve LOW BACK pain interference with ADLs from frequent to INTERMITTENT in order to resume independence in household mobility by 3wks.
PT REASSESS
PATIENT NAME: GENDER ASSISTIVE DEVICES
EVAL/SOC Tinetti
PMH INCLUDES STRENGTH 30 SEC CHAIR TEST
TINNETI BALANCE TINNETI GAITTUG:
Current Tinetti
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