Physical Therapy Case Paper

INTERNATIONAL REHAB MEDICAL OFFICE, P.C.
Provider: JINGLING TANG, M.D.
Tel: [phone] Fax:[phone]
Attn: outpatient physical therapy services.
Case #: 03138898
Re: Medical necessity of Physical therapy for patient ALBULENA AMETI ID: 302802744501 DOB: 06/25/1986
To Whom It May Concern:
The letter is to state new patient ALBULENA AMETI, 27 year-old female is suffering from hand pain and elbow pain, she came to our office on Aug. 28 2013. The patient reports of hand pain and so it is difficult for her to carry vegetables, milk, do some household chores and sometimes during bathing and grooming.
RANGE OF MOTION:
Elbow Flexion: Right: 0-110 degree, Left: 0-115 degree (Normal: 0-135
Patient was tested by Dynamic Gait Index scale to rule out any pathology concern with the fall. Patient scored a scale of 3 that is No impairment. TREATEMENT MODALITIES:
Ultrasound on elbow.
TENS.
Hot packs.
Therapeutic massage/Manual
Patient is enable to perform prone lying knee and hip flexion with 15 repetitions.
3. Patient is enable to perform push and pull within 15 inches after the treatment session at the end of the 2nd week.
SHORT TERM OBJECTIVE OF TREATMENTTime Frame: 1-4 weeks1. Enable the patient to do Active Lumbar strengthening exercise such as straight leg raise exercise, pelvic rotation exercise, bridging, clamshells, knee to chest exercise and lumbar stabilization with 3 RM(2 set of 10 ).2. Enable the patient to perform resistive elbow flexion extension with dumbells of 3lb with 15 repetition maximum with 1 rest interval
We would like to continue with physical therapy incorporating gym therapy as well Pilates to continue with overall strengthening, endurance training in order to improve functional mobility at home.
Very Truly Yours JingLing