RX:Bilateral solid-ankle AFOs. Orthopedic Surgeon Referral
Diagnosis:Thoracic myelomeningeal paraplegia and equinovarus contractures.
History:LATEX PRECAUTIONS were taken on this 4-year-old male today. He is taking Ditropan and a medication for an infection. He does not ambulate and sits by himself. He has not had surgery since his last visit, and he receives physical therapy at school. His previous devices were bilateral wraparound AFOs. I think that he would benefit more from a solid-ankle system with an anterior panel due to swelling. His feet are very chubby. Mom stated she had difficulty with the wraparound AFOs. She stated they pinched the front portion of his foot.
Evaluation:The patient has a scab and a cut on his left great toe. Mom stated this occurred approximately 1 month ago. It is healing. Range of motion on the left is 90 degrees. On the right, he is tighter, and range of motion is -5 degrees. He presents as a supinator on the right and pronator on the left. He has no clonus on either side. He has moderate tone on the right. He has no tone on the left. The orthotic goal today is to cast him and fit him with devices that will hold his foot in neutral alignment to give him support when he begins to stand.
Fabricate: bilateral solid-ankle AFOs.
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