Chapter 3 Review
86 Introduction to Medical Terminology
Copyright Goodheart-Willcox Co., Inc.
Medical Record Practice
Following is a physical therapy report for Khalil, the 18-year-old high school senior who was introduced in
the Case Study. Read Khalil’s medical record. Then, on a separate sheet of paper, write a definition for each
highlighted term and abbreviation.
HERMAN ORTHOPEDIC CLINIC
987 Medical Drive, Hospital City, US 12345
PHONE: (xxx) xxx-4321 FAX: (xxx) xxx-2910
PHYSICAL THERAPY NOTE
PT NAME: Khalil Larkins
ID NO: 86523497
DATE: 03/20/20xx
PCP: Dr. Evan Schumacher
Subjective Data: Pt. is an 18 y/o male c/o pain, swelling, and tenderness to L hamstring area.
Past Medical Hx: No prior surgeries.
Social Hx: No alcohol or drug use.
Current Limitations: Unable to amb and bear wt on L leg.
Limitation before Injury: N/A
Medications: Ibuprofen 800 mg Q8H PRN for pain.
Allergies: PCN
Current Pain Level: 8 on a 1–10 pain scale.
Pt Goal: Pain free, return of full ROM and strength.
Objective Data:
Injury Involved: L hamstring strain.
Treatment
Recommendations:
1. Rest the injury.
2. Ice to injured site Q2–3H.
3. Compression bandage to minimize bleeding into the tissue.
4. Elevation of the injury to decrease swelling.
5. Continue RICE treatment for the next 48 h.
6. Use crutches for next 48 h.
7. After 48 h, alternate ice and heat.
8. Return to PT department for initial stretching and strengthening
exercises in 72 h.