Orthopedics Study

Her arm shows forward flexion of about 90 degrees, abduction
60 degrees, external rotation 20 degrees, internal rotation
50 degrees, a well-healed scar.  X-ray shows healing and good maintenance of the fracture.  She is to continue with the range of motion exercises.  She may need the Rush rod removed at some time.  I will see her back here in about 3 months.

CHART NOTE

Her shoulder is improving with PT (physical therapy).  However, she still seems to have restrictions.  She can forward flex about 70 degrees to 80 degrees.  Abduction is only 50 degrees.  She probably has an element of adhesive capsulitis at this time.  She is going to continue her therapy.  In the future she may be a candidate for decompressive acromioplasty if the pain continues.

CHART NOTE

Seen approximately 5 weeks after a fracture of left humerus.  He has been in medial and lateral plaster slabs.  Today there seems to be a slight prominence laterally at the humerus, but the arm seems to be moving as a unit and it is not particularly tender.  X-rays shows some lateral angulation to the humerus, but definitely some callus formation.  I think that even with the deformity, it is mild, and I think the function will be very good.  He is therefore willing to leave things alone at the present and let it heal, and I will see him again in approximately 6 weeks.  He does not need a splint as long as he is careful with the arm.

CHART NOTE

Doing better.  She had the ulnar collateral ligament of her thumb repaired.  She now has almost symmetrical range of motion, but it is still somewhat tight.  It is not particularly painful.  The repair seems solid.  I think she just needs to work on the mobility a little bit longer and that she will be okay.  She will call me in about 2 months to let me know how she is doing.

CHART NOTE

Having a little pain over the distal radial ulnar joint when she lifts something.  There was no popping or clicking.  She has good range of motion and no deformity.  I suggested she just get a small weight and do some strengthening exercises and obtain a splint for her wrist, and she will call and let me know how this is going in the near future.

FOOTNOTE

Lines 7-9 (Page 1).  The degree word was added for clarity.

Line 19 (Page 1).  Alternative:  70-80 degrees.  The degrees word was added to 50 for clarity.

Line 32 (Page 1).  The word callus in the context functions as a noun, not an adjective; the physician is referring to the information of callus.

Line 36 (Page 1).  So as long as was edited to as long as. 
Alternative:  So long as.

Line 44 (Page 1).  She was changed to it for clarity.