: Painless.
: Constrained or painful.
: Anatomical position.
Physiotherapy report
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Name : Smith, Bill |
Medicare ID : 1010101019 |
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Reason : Car accident |
Folder ID : 1234 |
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Diagnosis: Fractured elbow |
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Treatment started on 1/1/1997 |
Number of treatment sessions: 26 |
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Dear Dr Wilson
After 26 sessions of treatment, we would like to inform you about the current state of Bill Smith.
Subjective statement
Elbow : We observe a nice recovery for this trauma. The patient doesn't feel any pain in the rest position. But the patient feel a slight pain in the area of the epitrochlea during daily life activities.
Objective statement
Flexion-extension motion is globally recovered. 12º are missing in extension and 8° in flexion.
Pronation-supination motion is almost recovered in spite of 10° missing at the end of pronation.
Legend used in range of motion diagram.
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: Painless. |
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: Constrained or painful. |
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: Anatomical position. |
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Left elbow: Flexion/extension movement
Range of motion
10/10/97 11/11/97
Strength.
With weight Flexion
Left elbow: Pronation/supination movement
Range of motion (position of the patient: Elbow in flexion)
10/10/97 11/11/97
Pain.
10/10/97 11/11/97
Analysis
Elbow : Ice application, mobilizations and muscle-development exercises.
Treatment plan
Elbow : Although recovered, we recommend extending treatments by two weeks.
Please accept all our distinctive thanks, Dr Montagnais.
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Date |
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The physiotherapist Dupont pht, 97-007 |
Your recommendations:
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Date |
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Doctor's signature |
(Return this copy through the patient. Thank you)