Module 5
PATIENT Michelle Gibbler DOB 05/16/1984 AGE 32 yrs SEX Female PRN MG875244
FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Michelle MIDDLE NAME - LAST NAME Gibbler SSN -
SEX Female DATE OF BIRTH 05/16/1984 DATE OF DEATH - PRN MG875244
ETHNICITY Not Hispanic or Latino
PREF. LANGUAGE
English
RACE Black or African American
STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 123 S. 45th St. ADDRESS LINE 2 - CITY Anytown STATE NY ZIP CODE 12345
CONTACT BY Home Phone EMAIL Michelle.Gibbler
@testpatient.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE - OFFICE EXTENSION
-
FAMILY INFORMATION
NEXT OF KIN Josephine Gibbler RELATION TO PATIENT Mother PHONE 5555555555 ADDRESS 2345 78th St
Haverhill, OH 45636
PATIENT'S MOTHER'S MAIDEN NAME
Johnson
Free cloud based EHR
Patient chart - Patient: Michelle Gibbler DOB: 05/16/1984 PR... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
1 of 1 4/7/17, 5:11 PM
Northstar Surgical Group
5678 Sunshine Way #500
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Preoperative Diagnoses: Endometriosis, dysmenorrhea, hx of intrauterine device perforation and exploratory surgery
Procedure Performed: Left salpingo-oophorectomy
Intraoperative Findings:
Perineum and vulva are without lesions. On bimanual examination, palpation revealed the uterus to be enlarged and retroverted. Intra-abdominal findings revealed normal liver margin, kidneys, and stomach. The left fallopian tube appeared to be normal size and showed evidence of a functional cyst. Multiple adhesions were present upon examination of the left ovary.
Procedure Details:
After informed consent was obtained, the patient was delivered to the OR and placed under general anesthesia. She was then prepped and draped in the usual, sterile manner. In a supine position, a Foley catheter was placed.
A sagittal midline incision was made and fascia was divided. The peritoneum was entered and observed. Washings were obtained. Exploration of the abdomen revealed findings as noted above. A retractor was placed and bowel was packed. Clamps were placed on the left broad ligament to improve traction. The retroperitoneal spaces were opened by incising lateral and parallel to the left infundibulopelvic ligament. The left ovarian ligament was identified and two hemostats were placed across the ovarian ligament. Using the Mayo scissors, the ovarian ligament was transected and dissected down the broad ligament. The left ovary was dissected in a similar fashion. The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder. After the pelvis had been irrigated, excellent hemostasis was noted. Retractors were repositioned to allow exposure for the left salpingectomy. Borders of the fallopian tube were identified. The posterior border of dissection was the retroperitoneal cavity, which was carefully identified and preserved. Ligaclips were applied to the left suspensory ligament. The left fallopian tube was dissected proximally. The suspensory ligament was dissected at its tubal attachment site, allowing the fallopian tube to be extracted. After the left salpingectomy was performed, excellent hemostasis was noted. All packs and retractors were removed and the abdominal wall was closed using a permanent monofilament suture. Irrigation of subcutaneous tissues was performed and a Jackson-Pratt drain was placed. At the completion of the procedure, all instrument, sponge, and needle counts were correct.
The patient was taken to the recovery are and then awakened from her anesthetic in stable condition.
Physician’s Signature John R. Benjamin, MD
Northstar Physical Therapy
6789 Sunshine Way #600
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Michelle Gibbler
DOB: 05/16/1984
Referring Physician: Nazir Asaad, MD
Diagnoses/Reason for PT Referral: Hx of Endometriosis and dysmenorrhea; 2 weeks post-surgical LSO
Onset date: 2/5/15 Relevant S&S: Pelvic pain, lumbalgia, metrorrhagia
Plan of Care
Interventions:
X Evaluation Gait training X Electrotherapy
X Patient Education Balance training/activities Prosthetic training
X Therapeutic Exercise Pulmonary physical therapy TENS
Transfer training X Ultrasound Teach bed mobility skills
Use of adaptive device Teach fall safety X Heat/cold therapy
X Therapeutic massage X Trigger point therapy
Treatment Frequency: Office visit 2x/wk for 6 weeks Modalities:
Patient education- Educate patient on muscular control for Kegal exercises. For 20 reps. Therapeutic exercise- Guided nutation/counternutation of the SI joints 10 reps x3
Therapeutic massage- Myofascial release 30 min Ultrasound- SI joints 10 min @ 1MHz; anterior pelvis 10 min @ 1MHz Electrotherapy- Interferential electrical stimulation 20min @ 80-150Hz - L-S spin Trigger point therapy- PRN (hip rotators, iliopsoas, QL, abdominals) Heat/cold therapy- Heat before tx, cold post-tx. Alternating heat/cold at home Physical Therapy Goals:
Current Level Goals
Moderate urinary incontinence daily Eliminate incontinence
Moderate-Severe pelvic pain rated 6/10 on average
Reduce pain to 3/10 over 6 weeks; re-evaluate for further therapy to eliminate pain
Tolerance to ADLs: Mod-severe pain is limiting work performance
Tolerance to ADLs: No pain, leading to no limitation to work performance
Pelvic/abdominal cramping at least 1x/week Eliminate pelvic/abdominal cramping
Discharge Plan: Re-evaluate after 6 weeks of treatment (12 visits)
Rehabilitation Potential:
Poor Fair Good X Excellent
Physical Therapist’s Signature Olivia Pham, D.P.T.