Enfermeria
Páginas: 2 (316 palabras)
Publicado: 11 de julio de 2012
7200 NW 7TH ST SUITE 200
MIAMI FLORIDA 33126
Patient’s Treatment Plan:
The patient ED with date of birth of 03/10/1940 came in to office on 08/17/2011 for the first time after amotor vehicle accident on 08/15/2011 patient was complaining of pain in his cervical, thoracic, lumbar and bilateral shoulder, which was described as worse with movements. Upon physicalexamination the patient had painful range of motion (ROM) on his cervical, thoracic and lumbar spine upon flexion, extension, lateral flexion, rotation and squatting. His cervical pain radiated tohis right shoulder. Upon examination of the right shoulder he had painful ROM. X-Rays anti-inflammatory medication, muscle relaxants and physical therapy were order. X-rays results showedmild thoracic rotoscoliosis toward the right side and straightening of the cervical spine physiologic lordosis due to muscle spasms. Patient came back on 4/01/2011 for a follow up to discussedhis x-ray results and check for progress, at that time the patient was still complaining of severe pain in the above mentioned locations so we continue with the physical therapy andmedication as order. On 5/31/2011 patient came back for a second follow up, at this time he had some improvement but was still complaining of pain in the same locations, medications were continuedand because of the improvement we decrease the frequency of the Therapy and schedule him to come back in 1 month.
At our facility the physical therapist notes also serve as a sign insheet since patients are require to sign in during every visit. Attached you will find copies of the physical therapist notes so you can see the patient’s signature when he/she signs in, copiesof X-rays results ( diagnostic test results) and copies of the doctor’s note which has the individual treatment plans for each visit.
Thank you,
________________________________________
MIAMI FLORIDA 33126
Patient’s Treatment Plan:
The patient ED with date of birth of 03/10/1940 came in to office on 08/17/2011 for the first time after amotor vehicle accident on 08/15/2011 patient was complaining of pain in his cervical, thoracic, lumbar and bilateral shoulder, which was described as worse with movements. Upon physicalexamination the patient had painful range of motion (ROM) on his cervical, thoracic and lumbar spine upon flexion, extension, lateral flexion, rotation and squatting. His cervical pain radiated tohis right shoulder. Upon examination of the right shoulder he had painful ROM. X-Rays anti-inflammatory medication, muscle relaxants and physical therapy were order. X-rays results showedmild thoracic rotoscoliosis toward the right side and straightening of the cervical spine physiologic lordosis due to muscle spasms. Patient came back on 4/01/2011 for a follow up to discussedhis x-ray results and check for progress, at that time the patient was still complaining of severe pain in the above mentioned locations so we continue with the physical therapy andmedication as order. On 5/31/2011 patient came back for a second follow up, at this time he had some improvement but was still complaining of pain in the same locations, medications were continuedand because of the improvement we decrease the frequency of the Therapy and schedule him to come back in 1 month.
At our facility the physical therapist notes also serve as a sign insheet since patients are require to sign in during every visit. Attached you will find copies of the physical therapist notes so you can see the patient’s signature when he/she signs in, copiesof X-rays results ( diagnostic test results) and copies of the doctor’s note which has the individual treatment plans for each visit.
Thank you,
________________________________________
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