Monday, June 2, 2008

Left Hemiparesis-Traumatic Brain Injury

Left free-ankle AFO Ankle Brace. Orthopedic Surgeon Referral

Traumatic brain injury and lefthemiparesis.

This 58-year-old male has no known allergies. The medications that he is taking are unknown at this time. He requires maximum assistance when ambulating. He has not had any surgery except after the initial accident, which occurred in 04/2000. He was riding his bike and was hit by a car. His wife was present during this, and she is unclear in regards to what was done. He did not have any fractures from the accident. He is receiving physical, occupational and speech therapy. He has not previously worn a device.

The patient has moderate tone on the left. His clonus is not sustained, and his alignment appears neutral. Range of motion at the ankle is to 90 degrees with the knee bent. This patient is very physically fit. Due to his tone and general strength that he continues to have, I was unable to obtain an accurate assessment of range of motion at ankle with the knee straight. I did not have this patient stand, as he requires maximum assistance to do so. The casting procedure went well. I spoke with his wife regarding the design of the device.

Fabricate left free-ankle brace AFO.

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