Occupational Therapy Medical Clinic Note Sample #1
EMPLOYEE’S DESCRIPTION OF INJURY: The patient is a (XX)-year-old right-hand dominant male who presents with complaint of left elbow pain. He apparently slipped off the back of a truck at about 10:30 last night, and he reached up and grabbed onto the handle of the door to try to brace himself and the brunt of the weight of his body was localized to the left upper extremity. As he kind of fell from the truck, he was able to stabilize himself by holding onto the handle; however, he injured the left elbow in the process, felt a pulling sensation to the elbow.
Today, he complains of significant pain, especially laterally along the elbow. He denies any numbness or tingling. No weakness to the upper extremity with the exception of weakness secondary to pain. There is no significant swelling or discoloration. No evidence of ecchymosis to the elbow.
REVIEW OF SYSTEMS: Remarkable for the musculoskeletal complaint and lack of neurologic complaints.
PAST MEDICAL HISTORY: Please see the triage sheet.
MEDICATIONS: Please see the triage sheet.
ALLERGIES: PLEASE SEE THE TRIAGE SHEET.
PHYSICAL EXAMINATION: VITAL SIGNS: Demonstrate a temperature of 97.8, blood pressure was 138/88, pulse was 88, and respiratory rate of 16. HEENT: Head is normocephalic and atraumatic. LUNGS: Clear to auscultation. CARDIOVASCULAR: Within normal limits. EXTREMITIES: Tenderness along the left elbow, especially along the lateral epicondylar area. The patient had full active range of motion, flexion, extension of the elbow, full supination and pronation of the left forearm. NEUROLOGIC: Left upper extremity was intact in the radial, ulnar and median nerve distributions. Gait was within normal limits. SKIN: Exam revealed no evidence of ecchymosis, traumatic lesions or vesicular lesions.
DIAGNOSTIC DATA: Radiograph of the left elbow demonstrated no evidence of fracture or dislocation. Joint space was preserved, and there was no evidence of hemarthrosis.
IMPRESSION: Elbow sprain with lateral epicondylitis.
PLAN: The patient is advised to ice the affected area for 10 minutes every hour while awake for the next 48 hours. He can then start with heat and stretches followed by ice. He was given a prescription for Naprosyn 500 mg 1 p.o. b.i.d. He will return to work with significant lifting restrictions, no lifting greater than 10 pounds, and he is to limit the use of the left arm as tolerated. He will follow up in 1 week. If pain persists, we will consider either MRI or occupational therapy depending on his progress over the next week.
Occupational Therapy Medical Clinic Note Sample #2
EMPLOYEE’S DESCRIPTION OF INJURY: The patient presents in followup from an emergency room visit for an injury he sustained to his right forearm on the above injury date. He indicates that he was walking an aisle at work, and as he entered the main aisle, a forklift truck carrying a pallet struck his right forearm. He indicates that the pallet struck his arm and not the forklift truck. Due to the injury, he went to the emergency room, where he was evaluated and x-rays were obtained. According to the patient, no bony abnormalities were noted. He was prescribed ibuprofen 600 mg to be taken 3 to 4 times per day, which he indicates he has been taking. He presently is stating he has marked improvement, where he has only minimal discomfort. He points to the area at the dorsal aspect of his distal forearm. He has no complaints of loss of motion or numbness or tingling. He voices no other complaints at this time.
PHYSICAL EXAMINATION: Examination today finds the patient to be alert and oriented, in no acute distress, with vital signs revealing a blood pressure of 112/78, pulse of 100, temperature is 98.6, and respirations are 22 and unlabored. Examination of the right upper extremity, comparing it to the unaffected contralateral side, reveals no soft tissue swelling, erythema, ecchymosis, open skin lesions, or gross deformity. He has full range of motion at the wrist, elbow and shoulder with strength testing versus resistance being 5/5. Deep tendon reflexes are brisk and symmetrical, being +2/4 at the biceps, triceps, and brachioradialis. Gross grip strength is strong and symmetrical. Distally, neurovascular status is intact. There is only minimal tenderness to palpation to the distal aspect of the forearm with no crepitance or step-off.
IMPRESSION: Healing contusion of the right forearm.
TREATMENT: Findings were reviewed with the patient. Following our examination, the patient was advised to continue the ibuprofen for an additional 2 to 3 days and then discontinue the medication. He can discontinue any further use of ice packs. No further recommendations are indicated at this time.
In regard to work restrictions, there are none.
FOLLOWUP APPOINTMENT: As of today’s date, the patient will be discharged to return on an as needed basis only.
Occupational Therapy Medical Clinic Note Sample #3
EMPLOYEE’S DESCRIPTION OF INJURY: Left ankle injury.
HISTORY OF PRESENT INJURY: The patient is a (XX)-year-old male who works at (XX). Approximately 7 hours prior to the encounter, the patient twisted his left ankle while attempting to restrain a patient at work. The patient can hardly step on his left foot and has been in pain, 8-1/2 over 10 on a scale of 10, when he steps on his left foot.
REVIEW OF SYSTEMS: Joint/ankle pain on left.
PAST MEDICAL HISTORY: Significant for asthma.
CURRENT MEDICATIONS: Albuterol.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION:
HEENT: Head is normocephalic, atraumatic. Conjunctivae and lids normal. Ears and nose externally without scars or masses. Tympanic membranes are bilaterally intact with light reflex. Oropharynx with normal mucosa of tonsils and pharynx.
HEART: Regular rate and rhythm without extra heart sounds.
LUNGS: Clear to auscultation bilaterally. Breath sounds clear and equal bilaterally.
SKELETAL: Digits and nails are normal.
GAIT AND STATION: The patient is limping. There is edema on either side of the left ankle and palpational laxity on the medial side of the left ankle as well as edema, tenderness. The patient’s left ankle flexion and extension appear to be intact with significantly reduced range of motion for side bending and rotation secondary to tenderness and edema.
NEUROLOGY: Cranial nerves II through XII are grossly intact without focal neural deficits. The patient was alert and oriented x 3 at the time of examination.
IMAGING: X-rays of the left ankle were taken. There does not appear to be any fractures. However, there is calcification of the ligamentous attachment to the medial malleolar head. There appears to be some density/discontinuity across the ligament. In addition, soft tissue swelling noted.
ASSESSMENT: Left ankle sprain, possibly grade 1 or grade 3.
PLAN:
- Rest, ice, compression, elevation were explained to the patient.
- Darvocet-N 100 one tablet by mouth every 6 hours for severe pain. The patient should not be driving under the influence of this medicine.
- Ibuprofen 800 mg one by mouth every 6 hours for pain.
- The patient to use crutches. No weightbearing on left foot until reevaluation by Orthopedics.
- The patient has been referred to Orthopedics for further management and treatment.
- The patient has been returned to work with the following restrictions until reevaluation by Orthopedics: Alternate standing, sitting. No pushing, no pulling. The patient to keep the air cast that was installed on his left ankle in the clinic until further instructions by Orthopedics.