Robert Macdonald

 
 2014 Jul 02 19:59:15 EDT 
 To: 195572268657
 Page: 03/657 
 From: Lauris Rigdon 
 
 Patient Self-Report 
 Patient Assessment/Diagnosis 
 History of Present Condition: 
 Patient presents with acute LBP and right hip pain that 
 presents with acute low back and right hip pain following 
 started on May 20th following elevator accident. Functional 
 accident that occurred on May 20th. Pt explains that she was battling with 
 established with patient input.  
 allow patient to return to prior level of function, 
 independence and safety. 
 Onset Date: May 20th 
 Comorbidities: 
 - Psychosocial: Battling with high anxiety, difficulty talking 
 about accident 
 - Car accident in with back pain and left shoulder (2007) 
 e Currently experiencing excessive vaginal bleeding (being 
 monitored by OBGYN) 
 Pre Morbid Level of Function: 
 - Independent prior to injury 
 Current Level of Function/Current Deficits: 
 - Unable to get into/out of car without onset of pain 
 - Unable to stand for prolong periods of time  
 - Unable to walk her dog due to fear of worsening 
 symptoms. 
 Work tasks: Desk job at home, mostly on the computer 
 Sleep disturbance: Reports no change in sleeping pattern 
 Imaging: 
 X-ray: no abnormal findings. 
 CT scan of abdomen and pelvis: results pending 
 Red flags: Pt denies all red flags including but not limited to 
 weight loss/gain > 10
 Patient Terri Ellis (DOB: 2001 Aug 08) 
 Treated by Nathaniel Powers, PT. DPT 
 DOS: 2014 Aug 23
 Page 2 of 57 of Plan of Care

