INTERNATIONAL REHAB MEDICAL OFFICE, P.C.
Provider: JINGLING TANG, M.D.
Tel: (718) 259-1636 Fax:718-343-1716
Attn: outpatient physical therapy services.
Case #: 03138898
Re: Medical necessity of Physical therapy for patient ALBULENA AMETI
ID: 302802744501 DOB: 06/25/1986
To Whom It May Concern:
The letter is to state new patient ALBULENA AMETI, 27 year-old female is suffering from hand pain and elbow pain, she came to our office on Aug. 28 2013.
The patient reports of hand pain and so it is difficult for her to carry vegetables, milk, do some household chores and sometimes during bathing and grooming.
RANGE OF MOTION:
Elbow Flexion: Right: 0-110 degree, Left: 0-115 degree (Normal: 0-135 degree)
Elbow Extension: Right: 0-135 degree, Left: 0-135 degree (Normal: 0-135 degree)
Shoulder Bilateral Flexion: Right: 0-100 degree, Left: 0-100 degree (Normal: 0-120 degree)
Shoulder Bilateral Extension: Right: 0-45 degree, Left: 0-45 degree (Normal: 0-60 degree)
Lumbar Flexion: 0-55 degree (Normal: 0-75 degree)
Lumbar Extension: 0-25 degree (Normal: 0-40 degree) STRENGTH:
Elbow region: Flexion: Right: 3/5 Left: 3/5
Elbow region: Extension: Right:3+/5, Left: 3/5 Lumbar Flexion :3+/5 Lumbar extension : 3+/5 GAIT: The patient shows normal gait while completely weight bearing on both the lower extremities.
Patient was tested by Dynamic Gait Index scale to rule out any pathology concern with the fall. Patient scored a scale of 3 that is No impairment.
Ultrasound on elbow.
Therapeutic massage/Manual Therapy.
Stretching of Hamstrings/Piriformis/Quadriceps and Abductors.
Strengthening of shoulder flexors/extensors/Lateral flexors and Lumbar Para-spinals.
Core Muscle strengthening exercises.
Pilates training exercises.
Progressive resistive exercises.
Home exercise Program
PRIOR FUNCTIONAL SCALES:
Patient was unable to push and pull within 15 inches due to severe shoulder pain
Patient was unable to perform resistive elbow flexion and extension for more than 10 repetitions.
Patient was unable...