Name of Insertable |
Specifics |
| Carpal Tunnel
Exam Normal. (Similar Insertables are available for multiple other standard conditions.) |
It is
noted upon examination of the left / right hand that there is normal sensation in all 5 digits to light
touch. There is no asymmetry noted regarding the sweating of the fingers. Tinels sign, in
which the transverse carpal ligament is tapped, is negative. Phalen's test, in which the
wrist is palmar flexed for 30 seconds is negative. Neither of these tests reproduces
paresthesias in the hand or fingers. There is no wasting of the thenar emminence. The
muscles of the thenar emminence are normal in strength and appearance. |
| Carpal Tunnel
Exam Abormal |
It is
noted upon examination of the left / right hand that there is not normal sensation in all 5 digits to light touch. Specifically,
there is abnormal sensation in state which fingers. Asymmetry is not noted regarding the sweating of the fingers. Tinels sign, in
which the transverse carpal ligament is tapped, is negative
/ positive. Phalen's test, in which the wrist is
palmar flexed for 30 seconds is negative / positive. Wasting of the thenar emminence is not noted. The strength of
the thenar emminence is not normal. |
| Cervical
Palpation Normal. Exam insertables are available for a wide variety of standard normals
and abnormals |
Palpation of
the cervical spine is normal. There are no masses noted. Neither tenderness nor spasm is
noted. There is no evidence of erythema. |
| Cervical
Palpation Spasm |
Palpation
of the cervical spine is abnormal. Mild / Moderate /
Severe spasm is noted at the C5-6, lower cervical, etc.
level on the right / left side. There is no evidence of erythema. There are no masses
noted. |
| Normal Examination of the Ankle |
Examination of the {LEFT / RIGHT / LEFT
AND RIGHT} {ANKLE / ANKLES} is within normal limits. There is satisfactory plantar and
dorsi-flexion as well as inversion and eversion. No crepitus is noted with motion. There
is no evidence of arthritis or of trauma. The skin is intact with no skin lesions,
cellulitis, ecchymosis, swelling or inflammation being noted. No scars are present. There
is no tenderness noted over the head of the Talus the Medial Malleolus, Lateral Malleolus
or Achilles Tendon. The Achilles Tendon is intact and there is adequate pull through of
this structure. The patient is not wearing a cast or other type of device on the ankle.
There is no evidence of snapping Peroneal Tendons. (His/Her) ligaments appear to be intact
with no evidence of instability present. Specifically the Anterior Talo-Fibular Drawer is
negative and the Deltoid Ligament appear to be intact. |
| Normal Xray Lumbar Region |
X-ray films of the lumbar spine obtained
in the office today in the AP, lateral, oblique, and L5-S1 cone-down projection are within
normal limits. There is neither lumbarization of S1 nor sacralization of L5. There is no
spondylolisthesis or spondylolysis. The disc spaces are well maintained as is the lumbar
lordosis. There are no significant degenerative changes present. No scoliosis is noted.
There are no fractures or dislocations. There are five lumbar vertebrae present and they
are in proper alignment. There is no evidence of an osseous lesion. |
| Prescription for Cataflam |
(He/She) was offered a prescription for
Cataflam 50mg. To be taken three times daily, by mouth, with food. (He/She) was offered
the standard precautions relating to anti-inflammatory usage, including avoidance of
alcohol. (He/She) was asked to take the Cataflam with food, and to avoid taking it on an
empty stomach. (He/She) was asked to discontinue its usage in the event of any untoward
symptomatology, including stomach upset. (Patient's first name) was asked to call the
office immediately in the event of any significant complications. |
| Injection of the Knee (Without
Aspiration) |
At this time I believe the patient would
benefit from a therapeutic and diagnostic injection. Therefore the {LEFT / RIGHT} knee is
prepped with a {TYPE OF SOLUTION, e.g. BETADYNE} solution and using sterile gloves and
technique, a solution consisting of {TYPE OF SOLUTION INJECTED, e.g. XYLOCAINE}, {__ OF
CC} cc, is injected into the knee. The patient tolerated the procedure well and there were
no complications. (He/She) is told to ice the area if there is any discomfort over the
next several days. (He/She) is also asked to contact the office if (he/she) notices any
untoward reaction from the injection. |
| Short Leg Walking Cast Application |
The patient's {LEFT / RIGHT} leg was
placed in a well padded short-leg non-walking cast in the office today. A Cast Care
booklet was provided and verbal instructions in cast care were offered as well. (He/She)
was told specifically to keep the cast clean and dry. (He/She) was told to call the office
for an early return appointment immediately if there is any increase in swelling or
pressure within the cast, or if the cast becomes damaged in any meaningful way. |
| PT Prescription for ACL injury |
(Patient Name)
Physical Therapy: 3x/week x 4 weeks
Dx: {LEFT/RIGHT/BILATERAL} ACL Injury Acute
Evaluate and treat, including;
Modalities as indicated to reduce edema and increase ROM
Instruction in home stretching and strengthening program
Emphasis on hamstring strengthening
Gait instruction with {NWB/PWB/WBAT/FWB}
ROM, strengthening and functional activities.
Progress toward prior level of function. |
| Recommend and Schedule ORIF Medial
Malleolar Fx. (Similar Insertables are available for Lat Malleolus, Bi-malleolar and
Tri-malleolar Fx's. |
I have recommended that (he/she) undergo
an Open Reduction and Internal Fixation of (his/her) {LEFT / RIGHT} medial malleolar
fracture. I have indicated that, in my opinion, this form of treatment is the most
appropriate at this point in time for (his/her) fracture. (He/She) has agreed to having
this procedure perfomed, and it is scheduled at an appropriate time and location. I have
cautioned against any form of unprotected weight bearing in the interim. |
| Light Duty Work Status because of
Cervical Injury. (Similar Insertables are available for Sedentary / Light Duty / Moderate
Duty and Heavy Duty, for each of Cervical, Lumbar, upper extremity and lower extremity
injuries. |
Because of the injury to the cervical
region, this patient is capable of light duty work only. Occasional lifting and carrying
of up to 20 pounds, and repetitive lifting and carrying of up to 10 pounds is acceptable.
No overhead work or any type of work which would require repetitive looking or placing the
hands over the head should be required of (him/her). In addition, the patient should avoid
strained or awkward positions of the neck. (He/She) should be allowed to move the neck
occasionally and should not be required to look in any one position continuously. The
patient should not be required to stand, walk, or sit in any position uninterruptedly for
more than 2 hours at a time. Within these restrictions (he/she) may work 5 days per week,
8 hours per day. |
| MMI Report for Cervical Injury. DRE II |
In my opinion the patient has a 5% whole
body permanent physical impairment rating, in accordance with the American Medical
Association Guides to the Evaluation of Permanent Impairment, Fourth Edition, Chapter 3,
Table #72 (page 110), due to (his/her) non-uniform loss of lumbar motion as well as muscle
guarding and nonverifiable radicular complaints as stated in the DRE (Diagnosis Related
Entity) Lumbosacral Spine Impairment Category II. |
| Return Appointment 2 months. (Available
from 1 day to 1 year.) |
I'd like to see (Patient's first name)
here in the office in 2 months. (He/She) has been instructed to make an appointment for 2
months from now. (He/She) was also told that in the event that (he/she) wishes to be seen
sooner, (he/she) need merely call the office and an earlier appointment will be scheduled. |
