Wiki PT coding

Omy13

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Kissimmee, FL
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How should this be coded?
Objective
TTP medial portal hole
No TTP medial or lateral joint line R knee
Negative medial and lateral compartment McMurray test 60 min
Description:BFR @70% LOA:
-bridges 30x15x15
-iso quad 3x30Switched to RLE BFR only:
-wall sits 2x1 min, 1x90 seconds
-step up 6 inch with 1 hand support 8x (d/c 2/2 ant knee pain)
-static split squat 1 hand support 10x RLE in front, 3x LLE in front
After BFR:
STS with LLE in staggered in front to force WB in RLE (tap butt to plinth) 8x
Squats 12lb 2x10
RDL 12lb 2x10
Standing hip flexor stretch
Education:
-HEP reviewed in great detail (new videos taken of squats, RDL and walk sit)
-discussed importance of gradual progression of weight during exercises
-discussed working through fatigue but not pain-discussed importance of feeling fatigue in RLE (if only feeling an exercises on the L side, you are favoring the L)
-gradually build tolerance to stairs (even if still negotiating with step to step patten and leading with LLE) to resumesubway commute to work (gradually progressing to this step)
Assessment
Pt continues to demonstrate favoring of LLE over RLE during exercises and functional tasks. PT addressed withstaggered stance STS to encourage WBing through RLE and VC to focus on symmetrical or favoring R side. PT and ptalso discussed re-training habits (ie not sitting with RLE extended forward) to begin to utilized RLE in more naturalway. Discussion of how pushing through fatigue is okay/good to strengthen the LE but not pushing through pain.HEP/at home expectations discussed in depth, no Q/C at this time. Pt continues to require skilled intervention toaddress impairments in LE strength, ROM, pain and gait order to return to PLOF.

PlanProgress pt within post op protocol and tissue healing timeframe to regain full strength, ROM and functional use of the RLE.
 
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