12/17/21, 11:40 AM MyChart - Visit Summary

Name: Austin Gross | DOB: 12/29/1987 | MRN: 08015321 | PCP: Alexandra Werner, MD

Progress Notes
Allison Smouse, PT,DPT at 12/04/21 1355
Insurance: Payor: CCO MEDICAID / Plan: CCO TRILLIUM TRI COUNTY / Product Type:
Medicaid /
Non-Medicare
OHSU PHYSICAL THERAPY EVALUATION
Past Medical History:
Diagnosis Date
• Anaplastic astrocytoma (HCC)  

Past Surgical History

Procedure Laterality Date
• Craniotomy and excision of neoplasm of brain Left 04/12/2021

Current Outpatient Medications: GENERIC EXTERNAL MEDICATION, Take 2 capsules by

mouth once daily. The Immunity supplement: 750 Mcg Vitamin A as Retinyl Palmitate 1000
mg Vitamin C ass Ester-C Calcium Ascorbate 15 mcg Vitamin D3 Cholecalciferol 2mg
Vitamin B-6 Pyridoxine Hydrochloride 666 mcg Folic Acid 6 mcg Vitamin B-12 300mcg
Biotin 10mg Pantothenic Acid as d-Calcium Pantothenate 25mg Magnesium as Magnesium
Oxide 15 mg Zinc as Zinc oxide, Disp: , Rfl:
glucosamine-msm-BosweL-herb182 500-500-33.3-70 mg oral tablet, Take 1 tablet by mouth
two times daily. 2 tablets three times daily, Disp: , Rfl:
Green Tea Leaf Extract (GREEN TEA) oral capsule, Take 250 mg by mouth three times
daily. , Disp: , Rfl:
lamoTRIgine (LAMICTAL) 100 mg oral tablet, Take 1 tablet by mouth two times daily., Disp:
60 tablet, Rfl: 3
LYSINE ORAL, Take by mouth once daily., Disp: , Rfl:
Melatonin 5 mg oral capsule, Take 20 mg by mouth once daily at bedtime., Disp: , Rfl:
multivitamin oral tablet, Take 1 tablet by mouth once daily., Disp: , Rfl:
ondansetron 8 mg oral tablet, Take 1 tablet 30-60 minutes prior to Temodar. May also take
every 8 hours as needed for nausea., Disp: 50 tablet, Rfl: 3
POLAPREZINC (ZINC CARNOSINE) ORAL, Take 2 tablets by mouth once daily., Disp: ,
Rfl:
prochlorperazine 10 mg oral tablet, Take 1 tablet by mouth every eight hours as needed for
nausea/vomiting. Max dose: 40 mg/day, Disp: 30 tablet, Rfl: 3
temozolomide 180 mg oral capsule, Take 2 capsules by mouth once daily at bedtime Take
on days 1 to 5 on a 28 day cycle. 200 mg/m2. BSA 1.81. Cycle 6., Disp: 10 capsule, Rfl: 0

Previous physical therapy treatment or alternative treatments for this condition includes:
none. Results of previous treatment: N/A.
Concurrent medical treatment: Following with neuro-onc.
 
SUBJECTIVE:
12/4/2021 History of presenting problem (chief complaint/MOI/onset date): Patient presents
with general deconditioning s/p diagnosis with Anaplastic astrocytoma of frontal lobe, tumor
resection 4/2021. Was pretty inactive at first and had to stay in bed for a long time. Toward
the end of radiation and first period of chemo had low T cell counts and started exercising a
lot and eating really well. Had some lower leg pain in the right leg and stopped doing
anything for a while. Pain is worse when it's cold. Stretching helps some.
Patient Functional Goals: To know what to do to help with the right leg pain and how to
exercise properly.
 
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12/17/21, 11:40 AM MyChart - Visit Summary
Diagnosis Date: 4/2021
Treatment history: L craniotomy, radiation, chemo currently
Date of surgery: 4/2021
Post-surgery precautions/expectations: nothing anymore
Current plan for treatment:
Chemo: still taking, had several months left
Radiation: 60 Gy in 30 fx and concurrent Temodar
 
Pain Rating:
-Now: 0/10
-Best: 0/10
-Worst: 3/10
Pain Location: right lower leg
Condition is becoming: Slightly better after stopping activity
Symptoms are: Intermittent
24 hour pain pattern: .
Symptoms are aggravated by: aggressive activity, cold, morning.
Symptoms relieved by: rest.
 
Fatigue rating: no problems on scale of 0 to 10
Sleep pattern: sleeping well.
Current hours of total sleep per night: 8
Wakes rested in morning: usually
 
Systems Review/Side Effects:
Vision: wnl
Hearing: wnl
Smell/taste: worse with chemo
Swallow: wnl
Sensation changes: wnl
Bowel/bladder: nt
Diet: wnl, eating keto
Drug use/tobacco use: cbd and thc at night
 
Living situation: lives with mom, independent with ADLs, needs some help when too
tired
Work History: on disability
Family demands:
Prior Level of Function:
Adaptive equipment patient currently has: .
Exercise equipment patient has access to: recumbent bike, no toe straps, yoga mats
and free weights and bands and other random things
No gym access
Current PA: not doing much
 
Anxieties or concerns about therapy:
 
Lab Results
Component Value Date
  HCT 43.4 11/12/2021
  HB 14.3 11/12/2021
  PLT 193 11/12/2021
  WBC 5.68 11/12/2021
 
 
Exercise guidelines for platelet counts
< 15: no exercise
15-20: gentle walking or stretching, no resistance
20-40: gentle resistance workout with light weights or resistance bands; stairs
40-60: stationary bicycle
Low count: no contact sports
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12/17/21, 11:40 AM MyChart - Visit Summary
 
Exercise guidelines for Hemoglobin:
12 or more exercise and walking as tolerated
10-12 light aerobics and light wts 1-2 lbs caution of elevated hrt rate & dysrhymias
<10 light ROM exercises and isometrics
8 or less no exercise other then AROM in bed, best to walk with someone for safety
 
 
OBJECTIVE:
Vitals: There were no vitals filed for this visit.
Cranial Nerves: III-XII
Posture: wnl.
Gait assessment:wnl
Observation:
Swelling:
Skin:
Palpation:mildly tender to palpation along right achilles
 
Strength Screen (Upper and Lower Quarter Screen):
Muscle Group Left Right
Shoulder Elevation 5/5 5/5
Shoulder Abduction 5/5 5/5
Shoulder External Rotation 5/5 5/5
Shoulder Internal Rotation 5/5 5/5
Elbow Flexion 5/5 5/5
Elbow Extension 5/5 5/5
Wrist Flexion 5/5 5/5
Wrist Extension 5/5 5/5
Thumb abduction /5 /5
Hip Flexion 5/5 5/5
Knee Extension 5/5 5/5
Knee Flexion 5/5 5/5
Dorsiflexors 5/5 5/5
Plantar flexors 5/5 5/5
Ankle inversion/eversion 5/5 5/5
Note 5/5=normal strength
*= pain with motion
BOLD= concerning
 
 
 
 
Outcome measure name Score 12/4/2021 Interpretation
5 time sit to stand: sec Normal values:
 
30 second sit to stand 22 reps, without Normal values;
use of UEs 30 y/o = 30 reps
Timed up and go sec Normal values ( in
seconds)
 
6 Minute Walk Test 2035 feet 30-39 yo: male 2346'
 
 
Treatment Today
Established home program with handout as listed below:
 
Home exercise program:
Access Code: FL8KXQ8Q
URL: https://OHSUrehabilitation.medbridgego.com/
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12/17/21, 11:40 AM MyChart - Visit Summary
Date: 12/07/2021
Prepared by: Allie Smouse
 
Exercises
Standing Bicep Curls Supinated with Dumbbells - 3 x weekly - 2 sets - 8-12 reps
Standing Bent Over Triceps Extension - 3 x weekly - 2 sets - 8-12 reps
Shoulder Overhead Press in Abduction with Dumbbells - 3 x weekly - 2 sets - 8-12 reps
Squat - 3 x weekly - 2 sets - 8-12 reps
Standing Clam with Resistance Loop - 3 x weekly - 2 sets - 8-12 reps
Standing Eccentric Heel Raise - 3 x weekly - 2 sets - 15 reps
 
Patient/Family Education: Progressive loading program and progressive biking program.
Start with 2x15 minutes at RPE 3-4 daily. 2 minutes of warm up
 
ASSESSMENT:
Austin is a 33 y.o. person who presents with deconditioning and right achilles pain in the
setting of. Impairments include mildly lower scores in 6 minute walk and 30 second sit to
stand compared to age matched norms and pain at right achilles. Subjective and objective
symptoms consistent with diagnoses. Impairments are limiting pt's ability to participate in
basic ADLs, work, and recreational activities without restrictions.
 
Functional Goals: due in 12 weeks
 
Goals Status at Eval Status at 02/05/2022
12/4/2021 or 6th visit
Pt will be able to run    
20 minutes without
pain
Patient will be able to    
walk 30 minutes
without pain
Patient will be able to    
cycle for 20 minutes
without pain
Independent with    
home exercise
program
 
PLAN: Therex, ROM, education, HEP, endurance, balance training
 
 
See topics above to identify problem areas and goals
Personal factors/Comorbidities:
Musculoskeletal and Oncology
No noted deficits
 
Moderate 1-2
Body structures & functions, Activity limitations, participation restrictions:
Musculoskeletal and Gait/Locomotion
Social and Recreational sport
High - 4 or more elements
Stability of condition:
MOD Slow progression of recovery,
Moderate - Evolving
Clinical decision making:
Multiple problems requiring prioritizing interventions, and Numerous co-morbidities and/or
personal factors require more complex clinical decision making
Moderate - Moderate complexity
Complexity:
Moderate - 97162

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12/17/21, 11:40 AM MyChart - Visit Summary
 
The patient requires services that can be safely and effectively performed only by a
qualified therapist to address the aforementioned and highlighted problems and goals.
Goals discussed and agreed upon with patient and/or family.
Individual cultural and social needs addressed.
Rehab Potential: Good, if Austin carries through with home exercise program.
 
This note is to serve as the discharge summary if the patient fails to attend further Physical
Therapy appointments or contact the therapist regarding any change in their status.

Allison Smouse, PT,DPT

OHSU PHYSICAL THERAPY SERVICES AT SOUTH WATERFRONT
 
Scheduled Appointment time: 1:55 PM
The patient was seen for a total of 50 minutes of treatment time. 50 minutes was in direct
contact care as described above and on completed flow sheets.
Treatment Interventions duration in minutes:
Procedure:Physical Therapy Evaluation and Therapeutic Exercise 15 min
Authorization information for first visit and progress reports
Procedure Codes: Re-evaluation 97002, Therapeutic Exercise 97110, Manual Therapy
97140, Therapeutic Activities 97530, Neuromuscular Reeducation 97112, Gait Training
97116, Self-care ADL 97535, Electrical Stimulation Attended 97032 and Electrical
Stimulation Unattended 97014
Minutes per session: 45
Total number of visits: 12
 
 
Frequency: Every 1-2 weeks Duration: 6 months (must exceed or match Medicare service
period request)
Service period from: 12/4/2021 to: - (Medicare must match duration or be no greater
than 90 days if proposed duration is greater than 3 months)
Start of care: 12/4/2021
Referral information Authorizing Provider: CALDWELL, ASHER [19162]
Onset/Referral Date: 8/31/21
Primary/Referral Diagnosis: R29.898 Muscular deconditioning
M76.61 Achilles tendinitis of right lower extremity
C71.1 Anaplastic astrocytoma of frontal lobe (HCC)
R53.0 Neoplastic (malignant) related fatigue
Next progress report 02/05/2022 or 6 visits
Insurance: Payor: CCO MEDICAID / Plan: CCO TRILLIUM TRI COUNTY / Product Type:
Medicaid /
Number visits authorized: 1 Number visits used: 1
Outcome Measure 12/4/2021

Activity 1 (3 point increase is significant for any one activity): 3 (cycling without pain)

Activity 2: 3 (Walking without pain)

Activity 3: 3 (Running without pain)

 
 

Patient Instructions
Allison Smouse, PT,DPT at 12/04/21 1355
Access Code: FL8KXQ8Q
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12/17/21, 11:40 AM MyChart - Visit Summary
URL: https://OHSUrehabilitation.medbridgego.com/
Date: 12/07/2021
Prepared by: Allie Smouse
 
Exercises
Standing Bicep Curls Supinated with Dumbbells - 3 x weekly - 2 sets - 8-12 reps
Standing Bent Over Triceps Extension - 3 x weekly - 2 sets - 8-12 reps
Shoulder Overhead Press in Abduction with Dumbbells - 3 x weekly - 2 sets - 8-12 reps
Squat - 3 x weekly - 2 sets - 8-12 reps
Standing Clam with Resistance Loop - 3 x weekly - 2 sets - 8-12 reps
Standing Eccentric Heel Raise - 3 x weekly - 2 sets - 15 reps
 

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