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Physical Therapy Progress Report1

This physical therapy progress report is for a 52-year-old male being treated for chronic back pain, weakness, and debilitation from chronic pain. The patient has attended physical therapy sessions involving pool therapy, lower and upper extremity strengthening exercises, and core stabilization exercises. While the patient reports some functional improvements, objective assessments found decreased strength and an antalgic gait, possibly due to being tested without pain medication. The physical therapy plan is to continue gym and pool exercises 6 times a week to improve functional mobility.

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678 views3 pages

Physical Therapy Progress Report1

This physical therapy progress report is for a 52-year-old male being treated for chronic back pain, weakness, and debilitation from chronic pain. The patient has attended physical therapy sessions involving pool therapy, lower and upper extremity strengthening exercises, and core stabilization exercises. While the patient reports some functional improvements, objective assessments found decreased strength and an antalgic gait, possibly due to being tested without pain medication. The physical therapy plan is to continue gym and pool exercises 6 times a week to improve functional mobility.

Uploaded by

ERAAO Tagum
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Physical Therapy - Outpatient Rehab

Progress Report
Description
Outpatient rehabilitation physical therapy progress note. A 52-year-old male referred to
physical therapy secondary to chronic back pain, weakness, and debilitation secondary to
chronic pain.
(Medical Transcription Sample Report)

SUMMARY
The patient has attended physical therapy from 11/16/06 to 11/21/06. The patient has 3 call
and cancels and 3 no shows. The patient has been sick for several weeks due to a cold as
well as food poisoning, so has missed many appointments.

SUBJECTIVE
The patient states pain still significant, primarily 1st seen in the morning. The patient was
evaluated 1st thing in the morning and did not take his pain medications, so objective
findings may reflect that. The patient states overall functionally he is improving where he is
able to get out in the house and visit and do activities outside the house more. The patient
does feel like he is putting on more muscle girth as well. The patient states he is doing well
with his current home exercise program and feels like pool therapy is also helping as well.

OBJECTIVE: Physical therapy has consisted of:


1. Pool therapy incorporating endurance and general lower and upper extremity
strengthening.
2. Clinical setting incorporating core stabilization and general total body strengthening and
muscle wasting.
3. The patient has just begun this, so it is on a very beginner’s level at this time.
ASSESSMENT DONE ON 12/21/06
STRENGTH
Activities Right Left
Great toe extension 3 3-

Dorsiflexion 3 3
Plantar flexion 3+ 3
Adduction 3 3
Abduction 4- 3
Knee extension 2+ 2+ painful bilaterally
Knee flexion 4 2

Stopped at this time secondary to pain stating significantly high. Knee flexion also tested
right 50 to 135, left 8 to 110.

GAIT: The patient significantly antalgic primarily to the left, increased weightbearing to the
right with antalgic gait to the left using single-point cane on the left. States unable to use it
on the right secondary to fused wrist as well as severe arthritic issues in the right hand.

ASSESSMENT
A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness,
and debilitation secondary to chronic pain. The patient presents today having missed
numerous appointments due to illness as well as no shows. The patient does feel he is
benefiting currently from ___ with increased ability to leave home and visit outside the
home, thus feel like he is putting on some muscle at this time. The patient's strength
decreased today possibly secondary to being tested in the morning and patient did not take
his pain medication though was very antalgic with all testing. This may not give a clear
presentation of comparison to the last session.
FUNCTIONAL OUTCOMES OF TREATMENT
Time Frame: 4 weeks
1. The patient will be independent with modified home exercise program, not met.
2. The patient will be independent with pool therapy, not met.
3. The patient will state increased ability of ambulation distance, continuing.

SHORT TERM OBJECTIVE OF TREATMENT


Time Frame: 3 weeks
1. The patient will be independent with home exercise program, continuing.
2. The patient will be independent with extended pool therapy, not met.
3. The patient will state functional improvement, endurance with outside activity at home,
this is met.

PLAN
We would like to continue with physical therapy incorporating gym therapy as well as pool
therapy to continue with overall strengthening, endurance training in order to improve
functional mobility at home. We would recommend 6 times a week, three times a week, 2
pool, 1 gym.

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