Breast Surgery Post OP Return Visit

Oncology physical therapy progress/treatment note Name: Jane Doe Visit date: 2023-10-15 MRN: 123456 Visit number: 3 Total treatment time: 60 mins Re-evaluation 97164 Manual therapy 97140 15 mins Therapeutic exercise 97110 20 mins Neuromuscular re-education 97112 10 mins Gait training 97116 15 mins PBM 10 mins Chief complaint: Post-operative pain and limited range of motion in the right shoulder Patient comments: "I feel some improvement, but the pain is still there, especially when I try to lift my arm." Response to treatment: Patient reports mild improvement in pain and increased range of motion. HEP compliance: Patient reports 80% compliance with the home exercise program. Examination/clinical findings Pain Present: 5/10 Best: 3/10 Max: 7/10 Location: Right shoulder Characteristic: Dull ache with occasional sharp pain Sensation: Normal sensation in the right upper extremity Circumferential measurements Baseline: 2023-09-01 Dominant hand: Right Right 2023-09-01 2023-09-15 2023-10-01 2023-10-15 Shoulder 40 cm 39 cm 38 cm 37 cm Elbow 30 cm 29 cm 29 cm 28 cm Wrist 18 cm 18 cm 17 cm 17 cm Non-dominant hand: Left Left 2023-09-01 2023-09-15 2023-10-01 2023-10-15 Shoulder 39 cm 39 cm 39 cm 39 cm Elbow 29 cm 29 cm 29 cm 29 cm Wrist 17 cm 17 cm 17 cm 17 cm Lymphedema measurement findings: No significant lymphedema noted Lymphedema signs/symptoms: None Edema findings: Mild edema in the right shoulder Integumentary system: Scars Well-healed surgical scar on the right shoulder Edema Mild edema present Ecchymosis None Erythema None Integrity Skin intact ROM: 2023-09-01 ROM: 2023-10-15 ROM comments: Improved range of motion in the right shoulder since the last visit Skilled services provided Manual therapy: Soft tissue mobilization and joint mobilization techniques applied to the right shoulder Therapeutic exercise: Shoulder flexion and abduction exercises, resistance band exercises Treatment duration: 4 weeks to right shoulder Assessment: Patient is progressing well with therapy, showing improvement in pain levels and range of motion. Additional communications: Discussed progress with the patient and encouraged continued compliance with the home exercise program. Plan: Continue with current treatment plan, reassess in 2 weeks.