Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Consult for New Wheelchair
A male referred to Wheelchair Clinic for evaluation for a new wheelchair.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS:
This 42-year-old male was referred to Wheelchair Clinic for evaluation for a new wheelchair. The client has a power wheelchair at home and it is two years old. However, he is unable to transfer throughout the community. The client does have two teenage children for which he does need to keep up with. He has a quickie revolution manual wheelchair that is greater than seven years old and in a complete state of repair. His past medical history includes TIA, complete spinal cord injury resulting from a gunshot wound in 1995, diabetes mellitus, right forearm fracture, bilateral hip fracture, right fifth tendon repair, left great toe surgery, and spinal surgery.SOCIAL HISTORY:
The patient lives with his wife and two children, ages 15 and 16 in a single floor apartment with rear entry. The client does not work; however, he does fix some type of computers as his hobby. His wife transports him in an oversized four-door vehicle.FUNCTIONAL STATUS:
The patient is modified and independent for all transfers utilizing the lateral technique. However, he does require a sideboard for tub transfers as well as car transfers. He is independent with his bed mobility. He is unable to ambulate due to his level of injury. At home, he does have an extended tub bench for showering. His wheelchair mobility has succeeded to modified independent level as well as wheelchair management and pressure release. He is dependent for community mobility with his manual wheelchair. The patient is unable to function, propel with ultra lightweight manual wheelchair throughout the community therefore putting him at the dependent level for this activity.ACTIVITY OF DAILY LIVING:
The patient is independent with his self care, completing this from the bed or chair level. He self casts every four to six hours a day independently and as previously mentioned completes this from the chair. Instrumental ADLs completed with assistance from his wife. He stays indoors 12 plus hours. His cognition is alert and oriented x 4.PHYSICAL EXAMINATION:
EXTREMITIES: Upper extremity range of motion is within functional limits, has 4-5 strength proximally and 5/5 distally. He is right hand dominant. Sitting posture reveals sacral sitting with a partially flexible posterior pelvic tilt. When taken out of his posterior tilt the client has loosed his trunk control. He has decreased postural control as he is unable to elevate his upper extremities greater than 90 degrees in unsupported sit.
His skin integrity is currently intact. His vision is within normal limits. Lower extremity range of motion is within normal limits with 0-5 strength throughout.EQUIPMENT RECOMMENDATION:
The patient was seen at clinic for evaluation for a new sitting system. He is unable to ambulate due to his level of injury. He is able to propel in ultra lightweight manual wheelchair. However, he does have difficulty propelling throughout the community when trying to maintain his level of activities with two teenage children. Therefore the following ultra lightweight wheelchair with powered six wheels is recommended.
1. Invacare Crossfire T6. As previously mentioned the client is unable to ambulate secondary to spinal cord injury. He does require manual wheelchair for all forms of mobility. He is very active in his wheelchair. He completes his self care as well as his __________ from the chair. He has two teenage children and he participates in community activities with. The patient also fixes computers at the wheelchair level.
2. Emotion power six wheels. The client has a history of right forearm fracture as well as fifth tendon repair. He has 4/5 shoulder strength bilaterally. He is an active computer user making it extremely difficult for him to propel his wheelchair over the varied terrain. Due to the patient's young age, he has many years that he will be depending on his upper extremities for all transfers and wheelchair mobility. It is important to be proactive in order to minimize the wear and tear on the joint as he already has upper extremity pain from repetitively propelling.
3. Flat-free inserts. The patient is at risk for flats due to his level of activity. He does require maintenance free wheelchair as he is unable to ambulate.
4. Removable covers. This is required for increased apprehension specifically in the winter.
5. Extra battery pack. This will allow the client to always have available power for these wheels. This is required as he is an extremely active user.
6. V-front end. This set up will keep his lower extremities close and prohibit external rotation and abduction of his lower extremities.
7. Frog leg suspension. This is required in order to absorb the shock in order to prevent his lower extremity from displacing from the foot plate.
8. Ergonomic seat with a tapered front end. This style will support the client at his widest point which is his pelvis/thigh/back of the knee.
9. Adjustable height push handles. This will accommodate various heights of the caregivers when pushed or bend up and down the stairs.
10. Soft roll caster. The client needs the extra width of a caster in order for use of community mobility rolling over the cracks as well as the stone in the community.
11. Plastic coated hand ends. This is required for increased __________ with propulsion.
12. Frame protector. This will protect his skin, specifically his lateral shins.
13. Positioning strap. This is required for pelvic positioning and safety.
14. Folding side guards. These will protect the clothing, however, may also be folded it in order to be moved out of the way for transfers.
15. Anti-tipper. These will prevent posterior tipping with all ramp and threshold use.
16. 3 inch locking Star cushion. The client is currently utilizing an air cushion without skin issues. The locking mechanism is required for stability with all of his transfers.
The above chair was decided upon after a safe and independent trial. This report will serve as the letter of medical necessity. We have staff who will follow up with the vendor and the patient to ensure that he has an appropriate effective manual wheelchair with power assist wheels. This request for consultation is greatly appreciated.
consult - history and phy., invacare crossfire t6, emotion power, flat-free inserts, removable covers, v-front end, frog leg suspension, ergonomic seat, adjustable height, soft roll caster, frame protector, positioning strap, anti-tipper, lightweight manual wheelchair, wheelchair clinic, lower extremities, manual wheelchair, wheelchair,
transcribed medical transcription sample reports and examples are provided by various users and
are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.
These transcribed medical transcription sample reports may include some uncommon or unusual formats;
this would be due to the preference of the dictating physician. All names and dates have been
changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or
place or anything else to real world is purely incidental.