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<s> [INST]Age: Greater than 56 What is your job and tell us about the nature of the work: Not specified Nature of Work: Not specified Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN)5. Past Rehabilitation Service: Not specified Previous Functional Level: Independent Any Precautions: Yes Please Specify Any Precautions: DM, HTN, on Mechanical Ventilation Any Relevant Investigations: Creatinine: 6.1, Blood Urea Nitrogen (BUN): >188, Potassium (K): 3.8Please specify Any Relevant Investigations: Creatinine: 6.1, Blood Urea Nitrogen (BUN): >188, Potassium (K): 3.8 Lives with: Family Floor: Upper floor Please specify which floor: First floor Stairs: Yes Location of Pain: Not specified Frequency of Pain: Not specified Pain Severity During Rest (V.A.S): Not specified Pain Severity During Activity (V.A.S): Not specified Pain Onset: Not specified Pain Course: Not specified Relieving Factors: Not specified Pain is Worse: Not specified Do you suffer from sleep problems: Yes Sleeping Posture: Supine Pillows: Two pillows Bed surface: Bed mattress Systolic Blood Pressure: 122 mmHg Diastolic Blood Pressure: 69 mmHg SPO2 (Blood Oxygen Saturation): 100% Heart Rate: 82 bpm Respiratory Rate: 20 breaths per minute How would you describe your muscle status: Not specified Please specify your muscle status: Not specified Do you feel pain in your shoulder: Yes Passive Range of Motion (PROM) for the Left shoulder: 170 degrees Passive Range of Motion (PROM) for the Right shoulder: 160 degrees Muscle Power for the Left shoulder: 3/5 Muscle Power for the Right shoulder: 0/5 Shoulder Motion: Flexion Additional Notes about Shoulder: None Do you feel pain in your elbow: Not specified Passive Range of Motion (PROM) for the Left elbow: Not specified Passive Range of Motion (PROM) for the Right elbow: Not specified Muscle Power for the Left elbow: Not specified Muscle Power for the Right elbow: Not specified Elbow Motion: Not specified Additional Notes about elbow: Not specified Do you feel pain in your wrist: Not specified Passive Range of Motion (PROM) for the Left wrist: Not specified Passive Range of Motion (PROM) for the Right wrist: Not specified Muscle Power for the Left Wrist: Not specified Muscle Power for the Right wrist: Not specified Wrist Motion: Not specified Additional Notes about Wrist: Not specified Do you feel pain in your fingers: Not specified Passive Range of Motion (PROM) for the Left hand: Not specified Passive Range of Motion (PROM) for the Right hand: Not specified Muscle Power for the Left hand: Not specified Muscle Power for the Right hand: Not specified Fingers Motion: Not specified Additional Notes about fingers: Not specified Do you feel pain in your knee: Not specified Passive Range of Motion (PROM) for the left knee: Not specified Passive Range of Motion (PROM) for the right knee: Not specified Muscle Power for the left knee: Not specified Muscle Power for the right knee: Not specified Knee Motion: Not specified Additional notes about knee: Not specified Do you feel pain in your ankle: Not specified Passive Range of Motion (PROM) for the left ankle: Not specified Passive Range of Motion (PROM) for the right ankle: Not specified Muscle Power for the left ankle: Not specified Muscle Power for the right ankle: Not specified Ankle Motion: Not specified Additional notes about ankle: Not specified [/INST] Impression: - General muscle weakness. - Bed stay. - Stiff joints (high risk for muscle shortening and joint stiffness). Problem List: - Right-sided weakness for strength exercise. Goals: - To Increase/Maintain Joint Range of Motion (ROM). - To Maintain/Improve Muscle Strength and Muscle integrity/flexibility. - To prevent further bedridden complications. - To educate family and caregivers about bed exercises and changing position every 2 hours. Assistive Device: - Heel support gel to reduce pressure ulcers. Treatment Plan: Special Tests: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test. 1. PROM exercises for both upper and lower limbs in all planes: 10 repetitions x 2 sets with rest intervals. 2. Gentle passive stretching on bilateral TA's (Tibialis Anterior): 7 seconds hold x 10 repetitions x 1 set with rest intervals. 3. Proprioceptive Neuromuscular Facilitation (PNF) exercises for limbs. Frequency of Treatment (sessions/week): For follow-up and daily physiotherapy: 5 sessions per week. Duration: Until discharge. Estimated Length of Physical Therapy (PT) Service: Until discharge. Additional Plan of Care in ICU: Not specified.</s>
<s> [INST] Age: Greater than 56; Job: N/A; Chronic Diseases: DM, HTN; Past Rehabilitation Service: N/A; Previous Functional Level: Independent; Precautions: Yes (DM, HTN, on Mechanical Ventilation); Relevant Investigations: B2M: 4.1 (Normal < 2.7), Cr CL: 65.8 (Normal < 51.5), SIF IgG/K with L: Insufficient; Lives with: Family; Floor: Ground floor; Stairs: No; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No; Sleeping Posture: Supine; Pillows: Two; Bed Surface: Bed mattress; Systolic Blood Pressure: 131 mmHg; Diastolic Blood Pressure: 75 mmHg; SPO2: 100%; Heart Rate: 94 bpm; Respiratory Rate: 22 breaths per minute; Muscle Status: Not specified; Shoulder Pain: No; Elbow Pain: No; Wrist Pain: No; Finger Pain: No; Knee Pain: No; Ankle Pain: No.[/INST]"Impression: General muscle weakness. Bed stay. Stiff joints (high risk for muscle shortening and joint stiffness). Problem List: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregivers about bed exercise and change position every 2 hours Goals: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Assistive Device: Not specified Treatment Plan: Special Tests: Passive Range of Motion (PROM) + Muscle tone + Muscle Power Test PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval PNF exercise for limbs Frequency of Rx: 5 sessions/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST]Age: Greater than 56; Job: Unemployed; Chronic Diseases: DM, HTN, Secondary Epilepsy post-stroke; Past Rehabilitation Service: No; Previous Functional Level: Fully Independent; Precautions: Yes (D, HTN, on Mechanical Ventilation); Relevant Investigations: PE on heparin; Lives with: Family; Floor: Upper floor; Stairs: First floor; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No; Sleeping Posture: Supine; Pillows: One; Bed Surface: Bed mattress; Systolic Blood Pressure: 153 mmHg; Diastolic Blood Pressure: 75 mmHg; SPO2: 98%; Heart Rate: 79 bpm; Respiratory Rate: Not specified; Muscle Status: 2/5 Flexion, 2/5 Abduction; Shoulder Pain: None; Elbow Pain: None; Wrist Pain: None; Finger Pain: None; Knee Pain: None; Ankle Pain: None. [/INST]"Impression: General muscle weakness, Prolonged bed stay, Stiff joints (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregivers about bed exercise and change position every 2 hours Goals: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Assistive Device: Not specified Treatment Plan: Special Tests: Passive Range of Motion (PROM), Muscle Tone, Muscle Power Test PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval Frequency of Rx: 5 sessions/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST]Age: Greater than 56; Job: Not specified; Chronic Diseases: DM, HTN; Past Rehabilitation Service: Not specified; Previous Functional Level: Independent; Precautions: Yes (DM, HTN, on Mechanical Ventilation); Relevant Investigations: Creatinine: 6.1, BUN: >188, K: 3.8; Lives with: Family; Floor: Upper floor; Stairs: First floor; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No; Sleeping Posture: Supine; Pillows: Two; Bed Surface: Bed mattress; Systolic Blood Pressure: 122 mmHg; Diastolic Blood Pressure: 69 mmHg; SPO2: 100%; Heart Rate: 82 bpm; Respiratory Rate: 20 breaths per minute; Muscle Status: 3/5 Abduction, 0/5 Flexion; Shoulder Pain: None; Elbow Pain: None; Wrist Pain: None; Finger Pain: None; Knee Pain: None; Ankle Pain: None. [/INST] "Impression: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregivers about bed exercise and change position every 2 hours Goals: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Assistive Device: Not specified Treatment Plan: Special Tests: Passive Range of Motion (PROM), Muscle tone, MUSCLE POWER TEST PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval Frequency of Rx: 5 sessions/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST]- Age : Greater than 56; Job : Not specified; Chronic Diseases : DM, HTN; Unemployment : No; Independent : Yes; Precautions : D, HTN; Relevant Medical History : CT Brain follow-up done; Known case of left MCA acute infarction; Evolutional changes of the left frontotemporal hypodensity which appear more hypodense and demarcated; New hyperdensity involving the left basal ganglia which shows interval decrease in the virtual noncontrast images, could represent contrast extravasation; Lives with : Family; Floor : Ground floor; Stairs : None; Location of Pain : Not specified; Frequency of Pain : Not specified; Pain Severity During Rest (V.A.S) : Not specified; Pain Severity During Activity (V.A.S) : Not specified; Pain Onset : Not specified; Pain Course : Not specified; Relieving Factors : Not specified; Pain is Worse : Not specified; Sleep Problems : No; Sleeping Posture : Supine; Pillows : Two; Bed Surface : Bed mattress; Systolic Blood Pressure : 140 mmHg; Diastolic Blood Pressure : 80 mmHg; SPO2 (Blood Oxygen Saturation) : 98%; Heart Rate : 90 bpm; Respiratory Rate : Not specified; Muscle Status : 2/5 Abduction, 2/5 Flexion; Shoulder Pain : None; Elbow Pain : None; Wrist Pain : None; Finger Pain : None; Knee Pain : None; Ankle Pain : None. [/INST]"Impression: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregivers about bed exercise and change position every 2 hours Goals: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Assistive Device: Not specified Treatment Plan: Special Tests: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval Frequency of Rx: 5 sessions/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST]Age: Greater than 56; Job: Not specified; Chronic Diseases: DM, HTN; Past Rehabilitation Service: Not specified; Previous Functional Level: Independent; Precautions: Yes (DM, HTN, on Mechanical Ventilation); Relevant Investigations: Creatinine: 6.1, BUN: >188, K: 3.8; Lives with: Family; Floor: Upper floor; Stairs: First floor; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No; Sleeping Posture: Supine; Pillows: Two; Bed Surface: Bed mattress; Systolic Blood Pressure: 122 mmHg; Diastolic Blood Pressure: 69 mmHg; SPO2: 100%; Heart Rate: 82 bpm; Respiratory Rate: 20 breaths per minute; Muscle Status: 3/5 Abduction, 0/5 Flexion; Shoulder Pain: None; Elbow Pain: None; Wrist Pain: None; Finger Pain: None; Knee Pain: None; Ankle Pain: None. [/INST] "Impression: Right-sided weakness for strength exercise, general muscle weakness, bed stay, stiff joints (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle Strength and Muscle Integrity/Flexibility, To Prevent Further Bedridden Complications, To Educate Family and Caregiver About Bed Exercise and Change Position Every 2 Hours Goals: Not specified Assistive Device: Heel Support Gel to Reduce Pressure Ulcer Treatment Plan: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test, Gentle Passive Stretching, PNF Exercise for Limbs Frequency of Treatment: Follow-up and daily physiotherapy 5x/week Duration of Treatment: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified "</s>
<s> [INST]Age: Greater than 56; Job: N/A; Chronic Diseases: Multiple Myeloma (IgG Kappa), Deep Vein Thrombosis (DVT); Past Rehabilitation Service: N/A; Previous Functional Level: Independent; Precautions: Yes (Mechanical Ventilation, DM, HTN); Relevant Investigations: B2M: 4.1, Cr CL: 65.8, SIF IgG/K with L: Insufficient; Living Situation: Family, Ground floor, No stairs; Sleep Problems: Yes (Supine posture, Two pillows, Bed mattress); Blood Pressure: 131/75 mmHg; SPO2: 100%; Heart Rate: 94 bpm; Respiratory Rate: 22 breaths per minute; Muscle Status: General weakness, bed stay, stiff joints; Shoulder Pain: Yes; Elbow Pain: Not specified; Wrist Pain: Not specified; Finger Pain: Not specified; Knee Pain: Not specified; Ankle Pain: Not specified. [/INST] "Impression: Acute ischemic stroke, general muscle weakness, bed stay, stiff joints (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle Strength and Muscle Integrity/Flexibility, To Prevent Further Bedridden Complications, To Educate Family and Caregiver About Bed Exercise and Change Position Every 2 Hours Goals: Not specified Assistive Device: Heel Support Gel to Reduce Pressure Ulcer Treatment Plan: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test, Gentle Passive Stretching, PNF Exercise for Limbs Frequency of Treatment: Follow-up and daily physiotherapy 5x/week Duration of Treatment: Until discharge Additional Plan of Care in ICU: Not specified "</s>
<s> [INST]Age: Greater than 56; Job: N/A; Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN); Past Rehabilitation Service: N/A; Previous Functional Level: Independent; Precautions: Yes (DM, HTN, on Mechanical Ventilation); Relevant Investigations: Not specified; Lives with: Family; Floor: Upper floor (First floor for some); Stairs: First floor (None for some); Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No (Yes for one); Sleeping Posture: Supine; Pillows: Two (One for one patient); Bed Surface: Bed mattress; Systolic Blood Pressure: Variable values; Diastolic Blood Pressure: Variable values; SPO2 (Blood Oxygen Saturation): Variable values; Heart Rate: Variable values; Respiratory Rate: Variable values; Muscle Status: Not specified; Shoulder Pain: Not specified; Elbow Pain: Not specified; Wrist Pain: Not specified; Finger Pain: Not specified; Knee Pain: Not specified; Ankle Pain: Not specified. [/INST] </s>
<s> [INST] Age: Greater than 56; Job: N/A; Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN); Past Rehabilitation Service: N/A; Previous Functional Level: Independent; Precautions: Yes (DM, HTN, on Mechanical Ventilation); Relevant Investigations: Not specified; Lives with: Family; Floor: Upper floor (First floor for some); Stairs: First floor (None for some); Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: No (Yes for one); Sleeping Posture: Supine; Pillows: Two (One for one patient); Bed Surface: Bed mattress; Systolic Blood Pressure: Variable values; Diastolic Blood Pressure: Variable values; SPO2 (Blood Oxygen Saturation): Variable values; Heart Rate: Variable values; Respiratory Rate: Variable values; Muscle Status: Not specified; Shoulder Pain: Not specified; Elbow Pain: Not specified; Wrist Pain: Not specified; Finger Pain: Not specified; Knee Pain: Not specified; Ankle Pain: Not specified.[/INST] Impression: Respiratory distress and desaturation. General muscle weakness. Bed stay. Decreased mobility (high risk for muscle shortening and joint stiffness). Problem List: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregivers about bed exercise and change position every 2 hours Goals: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Assistive Device: Not specified Treatment Plan: Special Tests: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval Frequency of Rx: 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST] Age: Greater than 56; Job: N/A; Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN); Past Rehabilitation Service: N/A; Previous Functional Level: Independent; Precautions: Yes (DM, HTN); Relevant Investigations: CT Brain follow-up; Lives with: Family, Ground floor; Stairs: None; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: Yes; Sleeping Posture: Supine; Pillows: Two pillows; Bed surface: Bed mattress; Systolic Blood Pressure: 140 mmHg; Diastolic Blood Pressure: 80 mmHg; SPO2 (Blood Oxygen Saturation): 98%; Heart Rate: 90 bpm; Respiratory Rate: Not specified; Muscle Status: General muscle weakness, bed stay, decreased mobility; Shoulder Pain: Not specified; Elbow Pain: Not specified; Wrist Pain: Not specified; Finger Pain: Not specified; Knee Pain: Not specified; Ankle Pain: Not specified.[/INST] Impression: Left MCA proximal occlusion Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregiver about bed exercise and change position every 2 hours Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST PROME's for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST] Age: between 36 and 45 years old; Job: Electrical Engineer - N/A; Chronic Diseases: PE, Left popliteal DVT, on Mechanical Ventilation; Past Rehabilitation Service: None; Previous Functional Level: Independent; Precautions: Yes, Post right limited hemicolectomy with end ileostomy on 29/1/2024 for iatrogenic bowel perforation; Lives with: Alone, Ground floor; Stairs: None; Location of Pain: Not specified; Frequency of Pain: Not specified; Pain Severity During Rest (V.A.S): Not specified; Pain Severity During Activity (V.A.S): Not specified; Pain Onset: Not specified; Pain Course: Not specified; Relieving Factors: Not specified; Pain is Worse: Not specified; Sleep Problems: Yes; Sleeping Posture: Supine; Pillows: Two pillows; Bed surface: Bed mattress; Systolic Blood Pressure: 137 mmHg; Diastolic Blood Pressure: 87 mmHg; SPO2 (Blood Oxygen Saturation): 95%; Heart Rate: 102 bpm; Respiratory Rate: 19 breaths per minute; Muscle Status: General muscle weakness, bed stay, tight muscles; Shoulder Pain: Not specified; Elbow Pain: Not specified; Wrist Pain: Not specified; Finger Pain: Not specified; Knee Pain: Not specified; Ankle Pain: Not specified. [/INST] Impression: Post-OP as a case of necrotizing pancreatitis. Post right limited hemicolectomy with end ileostomy on 29/1/2024 for iatrogenic bowel perforation. Problem List: General muscle weakness, bed stay, tight muscles (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregiver about bed exercise and change position every 2 hours Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST PROME's for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST] Age: Greater than 56, What is your job and tell us about the nature of the work: N/A, Nature of Work: N/A, Chronic Diseases: Hypertension (HTN), Past Rehabilitation Service: N/A, Previous Functional Level: N/A, Any Precautions: Please Specify Any Precautions: Yes, HTN, on Mechanical Ventilation, Any Relevant Investigations: Please specify Any Relevant Investigations: No, Lives with: Family, Floor: Please specify which floor: Ground floor, Stairs: None, Location of Pain: No, Frequency of Pain: N/A, Pain Severity During Rest (V.A.S): not specified, Pain Severity During Activity (V.A.S): not specified, Pain Onset: not specified, Pain Course: not specified, Relieving Factors: not specified, Pain is Worse: not specified, Do you suffer from sleep problems: Yes, Sleeping Posture: Left side, Pillows: Two pillows, Bed surface: Bed mattress, Systolic Blood Pressure: 125 mmHg, Diastolic Blood Pressure: 79 mmHg, SPO2 (Blood Oxygen Saturation): 98%, Heart Rate: 88 bpm, Respiratory Rate: 19 breaths per minute, How would you describe your muscle status: please specify your muscle status: General muscle weakness, bed stay, tight muscles (high risk for muscle shortening and joint stiffness), Do you feel pain in your shoulder: No, Passive Range of Motion (PROM) for the Left shoulder: not specified, Passive Range of Motion (PROM) for the Right shoulder: not specified, Muscle Power for the Left shoulder: 1/5, Muscle Power for the Right shoulder: 1/5, Shoulders Motion: Additional Notes about Shoulder: Abduction, Extension, Flexion, None, Do you feel pain in your elbow: No, Passive Range of Motion (PROM) for the Left elbow: not specified, Passive Range of Motion (PROM) for the Right elbow: not specified, Muscle Power for the Left elbow: not specified, Muscle Power for the Right elbow: not specified, Elbows Motion: Additional Notes about elbow: None, Do you feel pain in your wrist: No, Passive Range of Motion (PROM) for the Left wrist: not specified, Passive Range of Motion (PROM) for the Right wrist: not specified, Muscle Power for the Left Wrist: not specified, Muscle Power for the Right wrist: not specified, Wrist Motion: Additional Notes about Wrist: None, Do you feel pain in your fingers: No, Passive Range of Motion (PROM) for the Left hand: not specified, Passive Range of Motion (PROM) for the Right hand: not specified, Muscle Power for the Left hand: not specified, Muscle Power for the Right hand: not specified, Fingers Motion: Additional Notes about fingers: None, Do you feel pain in your knee: No, Passive Range of Motion (PROM) for the left knee: not specified, Passive Range of Motion (PROM) for the right knee: not specified, Muscle Power for the left knee: not specified, Muscle Power for the right knee: not specified, Knee Motion: Additional notes about knee: None, Do you feel pain in your ankle: No, Passive Range of Motion (PROM) for the left ankle: not specified, Passive Range of Motion (PROM) for the right ankle: not specified, Muscle Power for the left ankle: not specified, Muscle Power for the right ankle: not specified, Ankle Motion: Additional notes about ankle: None [/INST] Impression: Aneurysmal SAH with ICH, General muscle weakness, bed stay, tight muscles (high risk for muscle shortening and joint stiffness) Problem List: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complication, To educate family and caregivers about bed exercise and change position every 2 hours, Improve endurance and level of independency Goals: "To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complication, To educate family and caregivers about bed exercise and change position every 2 hours, Improve endurance and level of independency" Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST, Passive Circulatory ex PROM of bilateral lower limbs and Right upper limbs x 10 reps, Stretching of bilateral Achilles tendon muscles x 3 reps x 30 sec, Proper bed positioning, chest physio, Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week, Duration: until discharge, Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: Not specified </s>
<s> [INST] Age: Greater than 56, Job: N/A, Nature of Work: N/A, Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN), Ischemic Heart Disease (IHD), Old ischemic stroke (10 years ago) with residual left side weakness, Past Rehabilitation Service: None, Previous Functional Level: Max independent in Activities of Daily Living (ADL), Precautions: Yes, DM, HTN, on Mechanical Ventilation, Relevant Investigations: PE on heparin, CT scan showing faint subcortical hypodensity in the right corona radiata, Lives with: Family, Floor: Upper floor, Stairs: First floor, Location of Pain: N/A, Frequency of Pain: N/A, Pain Severity During Rest (V.A.S): N/A, Pain Severity During Activity (V.A.S): N/A, Pain Onset: N/A, Pain Course: N/A, Relieving Factors: N/A, Pain is Worse: N/A, Do you suffer from sleep problems: Yes, Sleeping Posture: Supine, Pillows: Two pillows, Bed surface: Bed mattress, Systolic Blood Pressure: 142 mmHg, Diastolic Blood Pressure: 82 mmHg, SPO2 (Blood Oxygen Saturation): 99%, Heart Rate: 72 bpm, Respiratory Rate: N/A, How would you describe your muscle status: General muscle weakness, bed stay, flaccid muscles (high risk for decreased muscle flexibility and joint stiffness), Do you feel pain in your shoulder: N/A, Passive Range of Motion (PROM) for the Left shoulder: 170 degrees, Passive Range of Motion (PROM) for the Right shoulder: 180 degrees, Muscle Power for the Left shoulder: 1/5, Muscle Power for the Right shoulder: 2/5, Shoulders Motion: Abduction, Flexion, Additional Notes about Shoulder: None, Do you feel pain in your elbow: N/A, Passive Range of Motion (PROM) for the Left elbow: N/A, Passive Range of Motion (PROM) for the Right elbow: N/A, Muscle Power for the Left elbow: N/A, Muscle Power for the Right elbow: N/A, Elbows Motion: N/A, Additional Notes about elbow: N/A, Do you feel pain in your wrist: N/A, Passive Range of Motion (PROM) for the Left wrist: N/A, Passive Range of Motion (PROM) for the Right wrist: N/A, Muscle Power for the Left Wrist: N/A, Muscle Power for the Right wrist: N/A, Wrist Motion: N/A, Additional Notes about Wrist: N/A, Do you feel pain in your fingers: N/A, Passive Range of Motion (PROM) for the Left hand: N/A, Passive Range of Motion (PROM) for the Right hand: N/A, Muscle Power for the Left hand: N/A, Muscle Power for the Right hand: N/A, Fingers Motion: N/A, Additional Notes about fingers: N/A, Do you feel pain in your knee: N/A, Passive Range of Motion (PROM) for the left knee: N/A, Passive Range of Motion (PROM) for the right knee: N/A, Muscle Power for the left knee: N/A, Muscle Power for the right knee: N/A, Knee Motion: N/A, Additional notes about knee: N/A, Do you feel pain in your ankle: N/A, Passive Range of Motion (PROM) for the left ankle: N/A, Passive Range of Motion (PROM) for the right ankle: N/A, Muscle Power for the left ankle: N/A, Muscle Power for the right ankle: N/A, Ankle Motion: N/A, Additional notes about ankle: N/A [/INST] Impression: Acute major PE. Problem List: "General muscle weakness, bed stay, flaccid muscles (high risk for decreased muscle flexibility and joint stiffness)" Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregiver about bed exercise and change position every 2 hours. Assistive Device: Heel support gel to reduce pressure ulcers Treatment Plan: Special Tests: Passive Range of Motion (PROM) + Muscle Tone + Muscle Power Test. PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Chest physio. Position exercise. Frequency of Rx (sessions/week): For follow-up and daily physiotherapy 5x/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: N/A</s>
<s> [INST] Age: Greater than 56, Job: Military, Nature of Work: N/A, Chronic Diseases: Right Lung Adenocarcinoma, Solitary Brain Mets post right sub-occipital craniotomy, Metastatic lesion excision, Dizziness, S.O.B, PE, DVT, Past Rehab Service: N/A, Previous Functional Level: Independent in ADL, Any Precautions: Specify - Yes, HTN, on Mechanical Ventilation, under Continuous Flow Syringe (CFS), Any Relevant Investigations: Specify - Yes, CT brain showed MASSIVE IVH, Lives with: Family, Floor: Specify - Upper floor, Third floor, Stairs: Yes, Location of Pain: Not specified, Frequency of Pain: Not specified, Pain Severity During Rest (V.A.S): Not specified, Pain Severity During Activity (V.A.S): Not specified, Pain Onset: Not specified, Pain Course: Not specified, Relieving Factors: Not specified, Pain is Worse: Not specified, Sleep Problems: Yes, Sleeping Posture: Supine, Pillows: Two pillows, Bed Surface: Bed mattress, Systolic Blood Pressure: 131 mmHg, Diastolic Blood Pressure: 85 mmHg, SPO2: 100%, Heart Rate: 92 bpm, Respiratory Rate: 18 breaths/min, Muscle Status: Not specified, Shoulder Pain: Yes, PROM Left shoulder: 150°, PROM Right shoulder: 130°, Muscle Power Left shoulder: 2/5, Muscle Power Right shoulder: 1/5, Shoulder Motion: Abduction, Extension, Flexion, Elbow Pain: Yes, PROM Left elbow: 40°, PROM Right elbow: 55°, Muscle Power Left elbow: 2/5, Muscle Power Right elbow: 1/5, Elbow Motion: Extension, Flexion, Wrist Pain: Yes, PROM Left wrist: 120°, PROM Right wrist: 110°, Muscle Power Left wrist: 1/5, Muscle Power Right wrist: 1/5, Wrist Motion: Flexion, Finger Pain: Yes, PROM Left hand: Not specified, PROM Right hand: Not specified, Muscle Power Left hand: Not specified, Muscle Power Right hand: Not specified, Finger Motion: Not specified, Knee Pain: Yes, PROM Left knee: Not specified, PROM Right knee: Not specified, Muscle Power Left knee: Not specified, Muscle Power Right knee: Not specified, Knee Motion: Not specified, Ankle Pain: Yes, PROM Left ankle: Not specified, PROM Right ankle: Not specified, Muscle Power Left ankle: Not specified, Muscle Power Right ankle: Not specified, Ankle Motion: Not specified. [/INST] Impression: INTRAVENTRICULAR HGE. Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complications, To educate family and caregiver about bed exercise and changing position every 2 hours. Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST + pitting edema, 1. PROMEs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. 2. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. 3. Chest physio. Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: not specified </s>
<s> [INST]Age: Not specified, Job: Not specified, Nature of Work: Not specified, Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN), Ejection Fraction (EF) 20%, Uncontrolled asthma, Chronic Kidney Disease (CKD), Past Rehabilitation Service: N/A, Previous Functional Level: N/A, Any Precautions: Specify - N/A, Any Relevant Investigations: Specify - N/A, Lives with: Family, Floor: Specify - Ground floor, Stairs: None, Location of Pain: Not specified, Frequency of Pain: Not specified, Pain Severity During Rest (V.A.S): Not specified, Pain Severity During Activity (V.A.S): Not specified, Pain Onset: Not specified, Pain Course: Not specified, Relieving Factors: Not specified, Pain is Worse: Not specified, Do you suffer from sleep problems: Yes, Sleeping Posture: Supine, Pillows: Two pillows, Bed surface: Bed mattress, Systolic Blood Pressure: 133 mmHg, Diastolic Blood Pressure: 84 mmHg, SPO2 (Blood Oxygen Saturation): 99%, Heart Rate: 88 bpm, Respiratory Rate: Not specified, Muscle Status: Specify - General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness), Shoulder Pain: Yes, PROM Left shoulder: 130 degrees, PROM Right shoulder: 140 degrees, Muscle Power Left shoulder: 1/5, Muscle Power Right shoulder: 2/5, Shoulders Motion: Abduction, Extension, Flexion, Additional Notes about Shoulder: None, Elbow Pain: Yes, PROM Left elbow: 140 degrees, PROM Right elbow: 145 degrees, Muscle Power Left elbow: 2/5, Muscle Power Right elbow: 2/5, Elbows Motion: Extension, Flexion, Additional Notes about elbow: None, Wrist Pain: Not specified, PROM Left wrist: Not specified, PROM Right wrist: Not specified, Muscle Power Left Wrist: Not specified, Muscle Power Right wrist: Not specified, Wrist Motion: Not specified, Additional Notes about Wrist: Not specified, Finger Pain: Not specified, PROM Left hand: Not specified, PROM Right hand: Not specified, Muscle Power Left hand: Not specified, Muscle Power Right hand: Not specified, Fingers Motion: Not specified, Additional Notes about fingers: Not specified, Knee Pain: Not specified, PROM Left knee: Not specified, PROM Right knee: Not specified, Muscle Power Left knee: Not specified, Muscle Power Right knee: Not specified, Knee Motion: Not specified, Additional notes about knee: Not specified, Ankle Pain: Not specified, PROM Left ankle: Not specified, PROM Right ankle: Not specified, Muscle Power Left ankle: Not specified, Muscle Power Right ankle: Not specified, Ankle Motion: Not specified, Additional notes about ankle: Not specified. [/INST] Impression: Septic shock Problem List: General muscle weakness. Bed stay. Decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM. To Maintain/Improve Muscle strength and Muscle integrity/flexibility. To prevent further bedridden complications. To educate family and caregivers about bed exercise and changing positions every 2 hours. Assistive Device: Heel support gel to reduce pressure ulcers Treatment Plan: Special tests - PROM + Muscle tone + MUSCLE POWER TEST PROMEs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Chest physio Frequency of Rx (sessions/week): For follow-up and daily physiotherapy 5x/week Duration: Until discharge Estimated Length of PT Service: Until discharge Additional Plan of Care in ICU: Not specified</s>
<s> [INST]Age: 16, Job: Retired, Nature of Work: not specified, Chronic Diseases: not specified, Past Rehabilitation Service: N/A, Previous Functional Level: INDEPENDENT, Any Precautions: Specify - Yes, PE, Mechanical Ventilation, Any Relevant Investigations: N/A, Lives with: Alone, Floor: Specify - Upper floor, Stairs: Third floor, Location of Pain: Abdominal, Frequency of Pain: During the day, Pain Severity During Rest (V.A.S): 1, Pain Severity During Activity (V.A.S): 5, Pain Onset: Gradual, Pain Course: Episode, Relieving Factors: Rest + medication, Pain is Worse: With movement, Do you suffer from sleep problems: Yes, Sleeping Posture: Supine, Pillows: Two pillows, Bed surface: Bed mattress, Systolic Blood Pressure: 117 mmHg, Diastolic Blood Pressure: 67 mmHg, SPO2 (Blood Oxygen Saturation): 99%, Heart Rate: 105 bpm, Respiratory Rate: 22 breaths per minute, Muscle Status: Specify - not specified, Shoulder Pain: Yes, PROM Left shoulder: 170 degrees, PROM Right shoulder: 170 degrees, Muscle Power Left shoulder: 2/5, Muscle Power Right shoulder: 1/5, Shoulders Motion: Abduction, Flexion, Extension, Internal rotation, Additional Notes about Shoulder: not specified, Elbow Pain: Yes, PROM Left elbow: 150 degrees, PROM Right elbow: 160 degrees, Muscle Power Left elbow: 2/5, Muscle Power Right elbow: 2/5, Elbows Motion: Extension, Flexion, Additional Notes about elbow: not specified, Wrist Pain: Yes, PROM Left wrist: not specified, PROM Right wrist: not specified, Muscle Power Left Wrist: not specified, Muscle Power Right wrist: not specified, Wrist Motion: not specified, Additional Notes about Wrist: not specified, Finger Pain: not specified, PROM Left hand: not specified, PROM Right hand: not specified, Muscle Power Left hand: not specified, Muscle Power Right hand: not specified, Fingers Motion: not specified, Additional Notes about fingers: not specified, Knee Pain: not specified, PROM Left knee: not specified, PROM Right knee: not specified, Muscle Power Left knee: not specified, Muscle Power Right knee: not specified, Knee Motion: not specified, Additional notes about knee: not specified, Ankle Pain: not specified, PROM Left ankle: not specified, PROM Right ankle: not specified, Muscle Power Left ankle: not specified, Muscle Power Right ankle: not specified, Ankle Motion: not specified, Additional notes about ankle: not specified. [/INST] Impression: Post right limited hemicolectomy with end ileostomy Problem List: General muscle weakness, bed stay, tight muscles (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complications, To educate family and caregiver about bed exercises and changing positions every 2 hours. Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST, 1. PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval, 2. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval, 3. chest physio, 4. strength exercises for lower limbs. Frequency of Rx (sessions/week): For follow-up and daily physiotherapy 5x/week. Duration: until discharge. Estimated Length of PT Service: until discharge. Additional Plan of Care in ICU: not specified</s>
<s> [INST] Age: Greater than 56, Job: Retired, Nature of Work: not specified, Chronic Diseases: Diabetes Mellitus (DM), Past Rehabilitation Service: N/A, Previous Functional Level: N/A, Any Precautions: Specify - Yes, Hypotension, tachycardia, Any Relevant Investigations: pH: 7.27, HCO3: 19.7, pCO2: 43, Lac: 0.6, Na: 132, K: 4.5, Glu: 117, MCV: 85, MCH: 27, Trop I: 0.022 (normal < 0.009), K: 5.3, Na: 133, c.Ca: 9.3, p: 7.3, mg: 1.88, UA: 10.7, WBCs: 11.57, Hb: 8.2, PLT: 412, Lives with: Family, Floor: Specify - Ground floor, Stairs: None, Location of Pain: not specified, Frequency of Pain: not specified, Pain Severity During Rest (V.A.S): not specified, Pain Severity During Activity (V.A.S): not specified, Pain Onset: not specified, Pain Course: not specified, Relieving Factors: not specified, Pain is Worse: not specified, Do you suffer from sleep problems: Yes, Sleeping Posture: Supine, Pillows: one pillow, Bed surface: Bed mattress, Systolic Blood Pressure: 116 mmHg, Diastolic Blood Pressure: 60 mmHg, SPO2 (Blood Oxygen Saturation): 98%, Heart Rate: 110 bpm, Respiratory Rate: not specified, Muscle Status: Specify - not specified, Shoulder Pain: Yes, PROM Left shoulder: 150 degrees, PROM Right shoulder: 140 degrees, Muscle Power Left shoulder: 2/5, Muscle Power Right shoulder: 2/5, Shoulders Motion: External rotation, Extension, Flexion, Internal rotation, Abduction, Additional Notes about Shoulder: not specified, Elbow Pain: Yes, PROM Left elbow: 140 degrees, PROM Right elbow: 130 degrees, Muscle Power Left elbow: 2/5, Muscle Power Right elbow: 2/5, Elbows Motion: Extension, Flexion, Additional Notes about elbow: not specified, Wrist Pain: not specified, PROM Left wrist: not specified, PROM Right wrist: not specified, Muscle Power Left Wrist: not specified, Muscle Power Right wrist: not specified, Wrist Motion: not specified, Additional Notes about Wrist: not specified, Finger Pain: not specified, PROM Left hand: not specified, PROM Right hand: not specified, Muscle Power Left hand: not specified, Muscle Power Right hand: not specified, Fingers Motion: not specified, Additional Notes about fingers: not specified, Knee Pain: Yes, PROM Left knee: 140 degrees, PROM Right knee: 130 degrees, Muscle Power Left knee: 2/5, Muscle Power Right knee: 2/5, Knee Motion: Extension, Flexion, Additional notes about knee: not specified, Ankle Pain: not specified, PROM Left ankle: not specified, PROM Right ankle: not specified, Muscle Power Left ankle: not specified, Muscle Power Right ankle: not specified, Ankle Motion: not specified, Additional notes about ankle: not specified.[/INST] Impression: Hypotension, tachycardia, pyelonephritis Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregiver about bed exercise and change position every 2 hours. Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST PROME's for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Chest physio Gentle strength ex for limbs Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: not specified</s>
<s> [INST]Age: 46-55 Job: Retired Nature of Work: Not specified Chronic Diseases: Asthma, Hypertension, Dyslipidemia, Hypothyroidism Past Rehabilitation Service: N/A Previous Functional Level: Poor Any Precautions: Hypothyroidism, Hypertension, Candida infection (CANDIDDA) Any Relevant Investigations: pH 7.27, HCO3: 19.7, pCO2: 43, Lactate 0.6, Na 132, K 4.5, Glucose 117, MCV 85, MCH 27, Troponin I: 0.022 (<0.009), K: 5.3, Na: 133, c.Ca: 9.3, p: 7.3, mg: 1.88, UA: 10.7, WBCs: 11.57, Hb: 8.2, PLT: 412, UTI, PE, DVT Lives with: Family Floor: Ground floor Stairs: None Location of Pain: No Frequency of Pain: No Pain Severity During Rest (V.A.S): No Pain Severity During Activity (V.A.S): No Pain Onset: Not specified Pain Course: Not specified Relieving Factors: Not specified Pain is Worse: Not specified Do you suffer from sleep problems: Yes Sleeping Posture: Supine Pillows: One pillow Bed surface: Bed mattress Systolic Blood Pressure: 116 mmHg Diastolic Blood Pressure: 60 mmHg SPO2 (Blood Oxygen Saturation): 98% Heart Rate: 110 bpm Respiratory Rate: Not specified How would you describe your muscle status: General muscle weakness, decreased mobility (high risk for muscle shortening and joint stiffness) Do you feel pain in your shoulder: Yes Passive Range of Motion (PROM) for the Left shoulder: 160 degrees Passive Range of Motion (PROM) for the Right shoulder: 170 degrees Muscle Power for the Left shoulder: 2/5 Muscle Power for the Right shoulder: 2/5 Shoulders Motion: External rotation, extension, flexion, internal rotation, abduction Additional Notes about Shoulder: None Do you feel pain in your elbow: Yes Passive Range of Motion (PROM) for the Left elbow: 140 degrees Passive Range of Motion (PROM) for the Right elbow: 170 degrees Muscle Power for the Left elbow: 2/5 Muscle Power for the Right elbow: 2/5 Elbows Motion: Extension, flexion Additional Notes about elbow: None Do you feel pain in your wrist: Not specified Passive Range of Motion (PROM) for the Left wrist: Not specified Passive Range of Motion (PROM) for the Right wrist: Not specified Muscle Power for the Left Wrist: Not specified Muscle Power for the Right wrist: Not specified Wrist Motion: Not specified Additional Notes about Wrist: Not specified Do you feel pain in your fingers: Not specified Passive Range of Motion (PROM) for the Left hand: Not specified Passive Range of Motion (PROM) for the Right hand: Not specified Muscle Power for the Left hand: Not specified Muscle Power for the Right hand: Not specified Fingers Motion: Not specified Additional Notes about fingers: Not specified Do you feel pain in your knee: Not specified Passive Range of Motion (PROM) for the left knee: Not specified Passive Range of Motion (PROM) for the right knee: Not specified Muscle Power for the left knee: Not specified Muscle Power for the right knee: Not specified Knee Motion: Not specified Additional notes about knee: Not specified Do you feel pain in your ankle: Not specified Passive Range of Motion (PROM) for the left ankle: Not specified Passive Range of Motion (PROM) for the right ankle: Not specified Muscle Power for the left ankle: Not specified Muscle Power for the right ankle: Not specified Ankle Motion: Not specified Additional notes about ankle: Not specified [/INST] Impression: AKI on top of CKD (Baseline Cr 2) secondary to (Infection & NSAIDs) Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complications, To educate family and caregiver about bed exercise and change position every 2 hours Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST 1.PROM's for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. 2. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. 3. chest physio 4. gentle strength ex for limbs Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU:not specified</s>
<s> [INST] Age: Greater than 56. What is your job and tell us about the nature of the work: Retired. Nature of Work: not specified. Chronic Diseases: Diabetes Mellitus (DM), Hypertension (HTN), Old CVA 1 year ago. Past Rehabilitation Service: No. Previous Functional Level: Independent. Any Precautions: Yes. Please Specify Any Precautions: Old CVA 1 year ago, HTN, DM. Any Relevant Investigations: Please specify Any Relevant Investigations: not specified. Lives with: Family. Floor: Please specify which floor: Upper floor. Stairs: Second floor. Location of Pain: Yes. Frequency of Pain: not specified. Pain Severity During Rest (V.A.S): not specified. Pain Severity During Activity (V.A.S): not specified. Pain Onset: not specified. Pain Course: not specified. Relieving Factors: Yes. Pain is Worse: not specified. Do you suffer from sleep problems: Yes. Sleeping Posture: Supine. Pillows: one pillow. Bed surface: Bed mattress. Systolic Blood Pressure: 113 mmHg. Diastolic Blood Pressure: 60 mmHg. SPO2 (Blood Oxygen Saturation): 99%. Heart Rate: 90 bpm. Respiratory Rate: not specified. How would you describe your muscle status: please specify your muscle status: not specified. Do you feel pain in your shoulder: Yes. Passive Range of Motion (PROM) for the Left shoulder: 180 degrees. Passive Range of Motion (PROM) for the Right shoulder: 170 degrees. Muscle Power for the Left shoulder: 2/5. Muscle Power for the Right shoulder: 2/5. Shoulders Motion: Abduction, Flexion. Additional Notes about Shoulder: None. Do you feel pain in your elbow: Yes. Passive Range of Motion (PROM) for the Left elbow: 170 degrees. Passive Range of Motion (PROM) for the Right elbow: 170 degrees. Muscle Power for the Left elbow: 2/5. Muscle Power for the Right elbow: 2/5. Elbows Motion: Extension, Flexion. Additional Notes about Elbow: None. Do you feel pain in your wrist: Yes. Passive Range of Motion (PROM) for the Left wrist: not specified. Passive Range of Motion (PROM) for the Right wrist: not specified. Muscle Power for the Left wrist: not specified. Muscle Power for the Right wrist: not specified. Wrist Motion: not specified. Additional Notes about Wrist: not specified. Do you feel pain in your fingers: Yes. Passive Range of Motion (PROM) for the Left hand: not specified. Passive Range of Motion (PROM) for the Right hand: not specified. Muscle Power for the Left hand: not specified. Muscle Power for the Right hand: not specified. Fingers Motion: not specified. Additional Notes about Fingers: not specified. Do you feel pain in your knee: Yes. Passive Range of Motion (PROM) for the Left knee: not specified. Passive Range of Motion (PROM) for the Right knee: not specified. Muscle Power for the Left knee: not specified. Muscle Power for the Right knee: not specified. Knee Motion: not specified. Additional Notes about Knee: not specified. Do you feel pain in your ankle: Yes. Passive Range of Motion (PROM) for the Left ankle: not specified. Passive Range of Motion (PROM) for the Right ankle: not specified. Muscle Power for the Left ankle: not specified. Muscle Power for the Right ankle: not specified. Ankle Motion: not specified. Additional Notes about Ankle: not specified. [/INST] Impression: post-op craniotomy Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM, To Maintain/Improve Muscle strength and Muscle integrity/flexibility, To prevent further bedridden complications, To educate family and caregiver about bed exercises and changing positions every 2 hours Assistive Device: HEEL SUPPORT GEL TO REDUCE PRESSURE ULCER Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST PROMs for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Chest physio Gentle strength exercises for limbs Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: not specified</s>
<s> [INST] Age: not specified. What is your job and tell us about the nature of the work: Salesperson - End-stage renal disease (ESRD), Bronchial asthma, Bipolar disorder, Hypertension (HTN), ANCA vasculitis. Nature of Work: not specified. Chronic Diseases: End-stage renal disease (ESRD), Bronchial asthma, Bipolar disorder, Hypertension (HTN), ANCA vasculitis. Past Rehabilitation Service: not specified. Previous Functional Level: not specified. Any Precautions: Yes. Please Specify Any Precautions: Bipolar disorder, HTN. Any Relevant Investigations: Please specify Any Relevant Investigations: not specified. Lives with: Family. Floor: Upper floor. Please specify which floor: First floor. Stairs: Yes. Location of Pain: not specified. Frequency of Pain: not specified. Pain Severity During Rest (V.A.S): not specified. Pain Severity During Activity (V.A.S): not specified. Pain Onset: not specified. Pain Course: not specified. Relieving Factors: not specified. Pain is Worse: Yes. Do you suffer from sleep problems: Yes. Sleeping Posture: Supine. Pillows: One pillow. Bed surface: Bed mattress. Systolic Blood Pressure: 95 mmHg. Diastolic Blood Pressure: 51 mmHg. SPO2 (Blood Oxygen Saturation): 98%. Heart Rate: 90 bpm. Respiratory Rate: not specified. How would you describe your muscle status: please specify your muscle status: General muscle weakness. Do you feel pain in your shoulder: Yes. Passive Range of Motion (PROM) for the Left shoulder: 170 degrees. Passive Range of Motion (PROM) for the Right shoulder: 170 degrees. Muscle Power for the Left shoulder: 2/5. Muscle Power for the Right shoulder: 2/5. Shoulders Motion: External rotation, Internal rotation, Abduction, Flexion. Additional Notes about Shoulder: None. Do you feel pain in your elbow: Yes. Passive Range of Motion (PROM) for the Left elbow: 170 degrees. Passive Range of Motion (PROM) for the Right elbow: 150 degrees. Muscle Power for the Left elbow: 2/5. Muscle Power for the Right elbow: 2/5. Elbows Motion: Extension, Flexion. Additional Notes about elbow: None. Do you feel pain in your wrist: not specified. Passive Range of Motion (PROM) for the Left wrist: not specified. Passive Range of Motion (PROM) for the Right wrist: not specified. Muscle Power for the Left Wrist: not specified. Muscle Power for the Right wrist: not specified. Wrist Motion: not specified. Additional Notes about Wrist: not specified. Do you feel pain in your fingers: not specified. Passive Range of Motion (PROM) for the Left hand: not specified. Passive Range of Motion (PROM) for the Right hand: not specified. Muscle Power for the Left hand: not specified. Muscle Power for the Right hand: not specified. Fingers Motion: not specified. Additional Notes about fingers: not specified. Do you feel pain in your knee: not specified. Passive Range of Motion (PROM) for the left knee: not specified. Passive Range of Motion (PROM) for the right knee: not specified. Muscle Power for the left knee: not specified. Muscle Power for the right knee: not specified. Knee Motion: not specified. Additional notes about knee: not specified. Do you feel pain in your ankle: not specified. Passive Range of Motion (PROM) for the left ankle: not specified. Passive Range of Motion (PROM) for the right ankle: not specified. Muscle Power for the left ankle: not specified. Muscle Power for the right ankle: not specified. Ankle Motion: not specified. Additional notes about ankle: not specified.[/INST] Impression: Septic shock Problem List: General muscle weakness, bed stay, decreased mobility (high risk for muscle shortening and joint stiffness) Goals: To Increase/Maintain Joint ROM To Maintain/Improve Muscle strength and Muscle integrity/flexibility To prevent further bedridden complications To educate family and caregiver about bed exercise and change position every 2 hours Assistive Device: Heel support gel to reduce pressure ulcer Treatment Plan: Special Test: PROM + Muscle tone + MUSCLE POWER TEST PROME's for both upper and lower limbs in all planes x 10 reps x 2 sets with rest interval. Gentle passive stretching on bilateral TA's x 7 sh x 10 reps x 1 set with rest interval. Chest physio Frequency of Rx (sessions/week): For follow-up and on daily physiotherapy 5x/week Duration: until discharge Estimated Length of PT Service: until discharge Additional Plan of Care in ICU: N/A</s>/

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