Welcome to the most comical collection of clinical clips the rehab world has ever known! The greatest excerpts taken straight from the pages of everyday physical therapy (and occupational therapy) documentation. You all know that we make mistakes from time to time; and that our patients can sometimes say some pretty weird stuff! Some of these are just so funny it would be a travesty not to share. As much as possible, all grammar and spelling has been maintained. For the most complete and up-to-date follow along on facebook and instagram:
- Subjective: Following his last appointment he does not recall any big flare or pain. Currently he is sore all over. He has had some episodes of sharp pains that causes him to feel faint. If he does the “wrong thing” like wear a fanny pack. He still has problems …
- Functional Activity #2: Lower booty dressing, Level of difficulty 6/10
Activity #1: Throwing a ball 3/10
Activity #2 Don coat/socks 4/10
Activity #3 Lift body into dump truck 4/10
- …basically has full ROM, normal strength, and is ambulating independently. I don’t really think that [pt] needs any more therapy but we will let the surgeon determine that tomorrow. Pt will call to let us know…
- DX: Hip pain. Showing improvement with pretty much every session. This past week she has had increased pain and decreased function. She did some light yard work but does not feel this was the exacerbating factor. She did recently add beans into her diet and that may be contributing to her increased pain. She is presenting with lateral hip and groin pain and lateral thigh and gluteal spasms …
- The treatments that will be used and expected outcome: Manual therapy to improve her soft tissue and facial distortions using a method called facial distortion model: See www.afdma.org
Was a falls assessment completed?: Yes
Indicate patient status condition: Alert (Oriented x3) or Comatose
- Patient Status: Client reports petting cat with abduction to improve ROM while enjoying good sensations in her hand and connecting with her cat.
- Pt is a [Man] who has had three of his knees replaced due to complications.
- Current Complaints/Gains: Pt states that she has been experiencing increased posterior left thigh pain after spending 3 hours watching wrestling.
- …yesterday fairly sudden onset and use heating pad and went to sleep and burned her mid back bilaterally short of having blisters. Most painful his left mid back paraspinals area below shoulder blade pain deep; she tolerated manual soft tissue mobilization well with no problem; treated with two units mango soft tissue mobilization and ultrasound in combination with electric stimulation and additional dose of the same her neck…
- Functional Activity #1: Hanging head in free space
- Patient Report: The patient reports that she is doing worse. She hasn’t been doing her exercises as much. Sitting still makes it worse. She is frustrated that things aren’t totally better yet. She recently got a new video game and has been “playing it obsessively“
- Patient History: Patient sleeps 29 hours a day, she gets tremors. LEFS 10/80
- Pt was traveling with skis. Did best to be smart so paid to rent a cart to get to check in. It was very awkward. Skis started to slide and had to catch it to save check-in computer. Pt low back seized up after landed. Pt could see his body hair was totally crooked, so he knew something was off
- New Goals: Pt is able to perform single leg stance on the left for 30 seconds to be able to run and wash leg in shower with less difficulty
Psycho-social/Work Status: She reports an active lifestyle being a single Mom with 5 kids. Responsible for all home duties/kids.
Marital Status: Married with 5 children (lives with spouse)
Pain: (9) out of 10 Comments: neck and lower back. pt is smiling, no signs of acute pain, minimal guarding
Disclaimer: These came from real clinical notes. Any and all identifiable information has been redacted or replaced. Any resemblance to known persons, patients, clients, providers or clinical entities is purely coincidental.