405 Faison Rd. Ste 105, Mount Pleasant, SC 29466- Phone: 843-352-2935 Fax: 843-352-2937 IniƟal EvaluaƟon/Plan of Care - 1/23/2024 Name: Smalls, Ella M (25666478) Physician: Payne MD, Alaina DOB: 3/24/1956 Age: 67 Sex: F Date of Injury: 1/2/2023 Primary/Rehab Diagnosis: Pain: Hip, Pelvic Region (R) DDD: Lumbar ICD10 Codes: M25.551, M51.17, M51.36, M54.59 Assessment: Ella M Smalls is a 67 y/o female who presents to Physical Therapy with signs and symptoms consistent of (R)Pain: Hip, Pelvic Region, DDD: Lumbar. PaƟent presents today with decreased Strength, Flexibility and increased Pain. PaƟent demonstrates a need for HEP EducaƟon. These deĮcits limit the paƟent’s ability to perform these tasks: Ascending stairs, Cleaning: Vacuuming, sweeping, Descending stairs, Driving, Sleeping > 6 hours, Squaƫng, Walking, Walking on uneven surfaces. PaƟent will beneĮt from skilled therapy to allow the paƟent to meet set goals and return to PLOF, in which the above noted funcƟonal acƟviƟes were not impaired. Primary Complaint: r pain coming from low back to r hip and down her leg. Nature of Injury: paƟent went to see the md due to thinking she had r hip arthriƟs. paƟent has Current Level of FuncƟon: PaƟent reports limitaƟons with Ascending stairs, Cleaning: ddd L4-5 in lumbar. paƟent has pain starƟng in the low back and going down the r leg and can Vacuuming, sweeping, Descending stairs, Driving, Sleeping > 6 hours, Squaƫng, Walking, go all the way to her foot. she drives a bus all day long and it causes an issue. Walking on uneven surfaces Prior Level of FuncƟon: PaƟent reports limitaƟons with r wrist is having sx and L breast biopsy and is having tumor removed. :**Pain Scale: At Rest 8/10; During AcƟvity 9/10; AROM PROM Hip/Knee MMT (0-5 scale) SigniĮcant Findings: R L R L R L ObservaƟons: Hip External 15 18 Hip Flexion ( L2) 4- 4- Flexibility: RotaƟon (0°-60°) Hip AbducƟon (L4-S1) 3+ 4- Piriformis: (R) vt; (L) vt Hip Internal 16* 18 Hip Internal RotaƟon 5 5 Hamstrings: (R) vt; (L) vt RotaƟon (0°-40°) Hip External RotaƟon 5 5 Gastrocnemius: (R) vt; (L) vt Knee Extension (L3) 5 5 BMI: BMI above normal. PaƟent provided nutriƟon or Knee Flexion (S2) 5 5 exercise counseling informaƟon.** Outcome Assessments: Date Assessment Score 1/24/2024 HOOS, JR. 36.4pts 1/24/2024 VR-12 Mental Component Summary 37pts 1/24/2024 VR-12 Physical Component Summary 32pts Plan of Treatment: 2x a week for 6 weeks Treatments: 97110 TherapeuƟc exercises , 97140 Manual therapy , 97112 Neuromuscular re-educaƟon , 97530 TherapeuƟc acƟviƟes , 97161-97163 PT EvaluaƟon , 97010 Cold pack , 97010 Hot pack These treatments will address the objecƟve and funcƟonal deĮcits as deĮned above The paƟent will be advanced safely and appropriately in order for the paƟent to progress towards his / her prior level of funcƟon. AddiƟonal exercises will be introduced, with progression to a comprehensive home exercise program upon discharge, to ensure carry over of funcƟonal gains achieved in the clinic. This treatment plan has been reviewed and agreed upon by the paƟent. Goals: Long Term Goals to be completed by: 03/05/2024 1. PaƟent will decrease pain score to 2/10 to allow for compleƟon of: Driving 2. PaƟent will increase strength to 5/5 bil glut med in order to allow for compleƟon of: Ascending stairs 3. PaƟent will improve HOOS, JR. Outcome Survey to 75% to allow for compleƟon of: Walking Electronically Signed By: Melanie Billman, PT, License 8933 January 28, 2024 7:23 PM To Be Completed by Physician I cerƟfy the need for these services furnished under this plan of treatment and while under my care. Revise plan of care as follows: Physician: Payne MD, Alaina Physician Signature: Date:
i want to take the text from Pain scale to outcome Assessements
can u please scrape



