The patient is a 47 year-old female whose chief complaint is right leg weakness and instability which adversely effects her ability to walk. Relevant past medical history includes lumbar disc herniation, fibromyalgia, and being deceased as of October 31 2014. She reports an abrupt onset of symptoms at that time, and describes the mechanism of injury as grabbing, biting and scraping of the right lower leg. She reports that her symptoms have gradually worsened as the leg continues to decay.
The patient has not underwent a recent medical exam or diagnostic imaging.
The patient rates her pain as 0/10.
Significant trauma of the right lower extremity is observable, with weepy goo pockets of mushflesh. The common peroneal nerve is exposed over a gnawed fibular head. The right Achilles tendon is absent and the plantar fascia is not tender to palpation. Pedal pulse is 0 beats/min. Patient is unable to detect 10 g monofilament light touch. The patient ambulates with right foot flat at initial contact phase of gait, with lateral trunk lean to the right and right hip adduction during weight acceptance, and there is no supinatory propulsion during late stance phase. Functional limitation include right leg weakness and instability which creates difficulty with activities of daily unliving. The patient goals include increased strength and stability of the right leg to enable return to stalking humans without complication.
Applicable ICD-10 diagnosis codes include:
M36X221 - bit by a zombie
F329 - zombie
JKLMNOP34 - ataxic confabulations
6789876 - abnormality of gait
S92.1 - stanky leg
Todays treatment included fitting patient with rigid rocker bottom shoes and Arizona Brace to provide external stability to the foot and ankle. Following this, the patient demonstrated improved speed of walking including acceleration and change of direction with minimal energy leak.
The agreed upon goals and treatment plan were discussed with the patient. She will attend physical therapy for two to three visits over the next two weeks to allow for sufficient help l;dka#$%%d_!@*khhhhhjkljkl