Physical Examination This is a well developed well nourished elderly female in

Physical examination this is a well developed well

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Physical Examination: This is a well-developed, well-nourished elderly female in no acute distress. She had moderate discomfort on movement. Her HEENT exam was essentially normal. Her lungs were clear. Heart had a regular rate and rhythm. Abdomen was soft and nontender. Her rectal area showed good tone. Her back showed moderate tenderness to palpation in the upper lumbar and lower thoracic area. Neurologically, she was completely normal with cranial nerves being intact. Motor was 5/5 in all extremities except for the left extremity, which was not examined secondary to the arm being in a splint. She had deep tendon reflexes 2+ and equal. Her sensory exam was normal. Hospital Course: The patient was admitted and on the day following admission, she had a bone scan that revealed moderate degenerative joint disease of the T&L ( thoracic and lumbar ) spine with no evidence of acute compression fractures. The patient was placed on bed rest and was started with physical therapy and ambulation with which she has steadily progressed with decreasing pain and tenderness. The patient is now ambulating using a walker with a platform for her wrist splint. Social Services and Physical Therapy were consulted. She is ambulating well with her walker and it is felt she will do well staying with members of her family over the next 10 to 14 days, after which time she will be able to go back to living in her apartment. The patient will follow up with the Orthopedic Clinic in 10 to 14 days. She will follow up with her private physician for the wrist fracture upon discharge. Discharge Medications: Tylenol #3, one or two p.o. q 4-6 h. p.r.n.; Fosamax 5 mg daily, and she will continue with her Calcium t.i.d. OUTPATIENT OFFICE ENCOUNTER Carol Champion is a 46-year-old retired professional ice skater who was seen initially by Physical Therapy on 12/30/10. She indicates that she fell on her left shoulder and arm while ice skating on 12/29/09. She was first seen by Beth Ranowski and given
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Codman's exercises. The patient continued to have shoulder pain and saw Dr. Owens on 1/04/10 and was referred for physical therapy due to her complaints of limited range of motion in the left shoulder secondary to pain. Her assessment was rotator cuff of the left shoulder with limitations in active range of motion. DISCUSSION QUESTIONS 1. Review the Discharge Summary, provide the following in your post. A. What does it mean in the spinal X-ray when it says, "These could not be ruled out as new or old fractures?" B. What other terms in this case study refer to structures and conditions of the musculoskeletal system?
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  • Spring '19
  • Rousse, Justin R.

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