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
eval
SUBJECTIVE
PATIENT STATED HER LEGS FEEL WEAK AND SHE GETS TIRED EASILY.
MMT
GROSS MUSCLE STRENGTH IN RIGHT HIP 4+/5 LEFT HIP 4+/5 IN RIGHT KNEE 4+/5 LEFT KNEE 4+/5 IN RIGHT ANKLE 5/5 LEFT ANKLE 5/5
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PT EVAL
PATIENT NAME:
SELECT AGE: GENDER ASSISTIVE DEVICES
PATIENT AND DISCHARGED TO HOME ON
PMH INCLUDES STRENGTH 30 SEC CHAIR TEST
TINNETI BALANCE TINNETI GAITTUG:
LIVING SITUATION LIVES WITH A
