FREELANCER

Freelance Jobs

Tuesday, December 1, 2009

Samples Files of MT


Patient Name:_______ Chart#: ______


FU: The patient is here for follow-up of her right shoulder and both knees. The right shoulder is improved a little bit with physical therapy.

PE: Range of motion is full. There is still some pain with extremes. There is some pain with resisted abduction but no weakness. Her knees are not improved at all.

XR: X-rays done last time shows “bone-on-bone” on the medial side.

PLAN: She is ambulating with a cane. She is using Tylenol Arthritis and Motrin. She would like to proceed with knee replacement surgery, probably bilaterally. We will set her up probably at the end of January. She and her son will come back and see us in about a month and we will review the procedure and come up with a definitive date at that time.


Doctors Sign

No comments:

Post a Comment