PART II

PT INITIAL EVALUATION
GENERAL INFORMATION
Patients Name:
Age:
Sex:
Address:
Civil Status:
Handedness:
Occupation:
Religion:
Referring Dr:
Referring Unit:
Rehab Dr:
Date of Admission:
Date of Referral:
Date of IE:
Diagnosis:

A.I.
23 y/o
Female
San Esteban, Ilocos Sur
Single
(R)
Student
Roman Catholic
Dr. C
In Patient
Dr. E
January 4, 2016
January 4, 2016
January 11, 2017
Torn medial meniscus of the (L) knee; S/P arthrotomy with
medial menisectomy on (L) knee

SUBJECTIVE
C/c:
sumakit itong aking kaliwang tuhod noong nagtraraining ako ng
taekwondo
Pt. c/o deep nagging pain on his (L) knee over the joint line with PS
7/10.
HPI:
Present condition started 1 week PTIE when the patient injured her L
knee while having a training in taekwondo. Patient attempts to kick the head
of the challenger suddenly she was not on the right position. As her pivots to
change direction, the challenger kick (L) knee and suddenly stumbled down
on the platform.(Pt. is not in good position) Patient stated that she felt sudden
deep nagging pain on the (L) knee ps 10/10. The Coach approached her and
applied first aid which includes rest, icing,and compression and was rushed
immediately to the emergency room at SNH via tricycle ~15min. Patient
undergone X-ray and MRI(see ancillary procedure) which revealed that she
has medial meniscus tear on the (L) knee. She took pain reliever as
necessary ps 7/10. On the same day, patient was scheduled to the OR, and
underwent arthrotomy with medial menisectomy to suture the torn menisci.
She was discharge the day after the surgery and she was referred to PT
Rehab under Dr. E for further treatment and evaluation.
Ancillary procedure:
Date/Procedure

Results

MRI and X-ray:

1/24/17 SNH

Torn medial meniscus of the(L) knee; S/P

arthrotomy with medial menisectomy on (L)
knee

Medication:
Drug
Mefanamic acid
500mg
PMHx:
(-)
(-)
(-)
(-)
(-)
(-)

Indicati
on
Pain
reliever

Dosage
As
necessar
y

DM
Hospitalization
HPN
Heart Disease
lung disease
Arthritis

FMHx:
HTN
Heart Disease
Diabetes

Father
(-)

Mother
(-)
(-)
(-)

(-)
(+)

PSEHx:
Pt has an active lifestyle. Pt has no Hx of smoking and a non-alcoholic
beverage drinker and not abusing any substance. He lives in a 2-storey
building with his mother, father and brother. Main door to Living room: ~8
steps; Living room to Bed room: ~15 steps; Main door to Kitchen:
~18steps ; Comfort room to Bed room: ~10 steps. Pt room is situated at
the first floor
OBJECTIVE
VS:
BP:
PR:
RR:
T:

90/70 mmHg
75 bpm
15 cpm
36.7 C

OI:
Ambulatory c AD (axillary crutches)
A/C/C
Mesomorph
(+) swelling on (L) knee

(+) stitches on (L) knee (6 stitches)

(-) attachments
(-) skin trophic changes
(-)Edema
(-) bruising
(-)atrophy
Palpation:
Hyperthermic on (L) knee and normothermic on other exposed areas
Normotonic in all areas
(+) Grade 2 tenderness
(-) muscle spasm
(-) edema
(-) atrophy
ROM:
All major joints of (R) UE/LE are WNL actively and passively done pain
free except:
MOTION
Knee
flexion
Knee ext.

Normal

Active

Passive

Differenc
e

End - feel

0-135

0 125

0 135

10

Soft

135-0

125 0

135 0

10

Firm

Findings: LOM
Significance: 2 to pain
MMT:
All major muscle groups are grossly graded 5/5.
Sensory Testing:
STD used: pin for pain, brush for light touch & thumb for deep
pressure.
Findings:
100% intact sensation
Significance:
Intact sensory pathway
DTR:
LEGEND:
++
++
hyporeflexia
++
hyperrelexia

++
++
++

0 - areflexia
+++ - normoreflexia
+++ -

++++ clonus
++

++

++

Findings:
Normoreflexive on both UE/LE
Significance:
Intact reflex arc

++

PA: N/T
GA: N/T
ADL: Patient is fully independent in all aspects of ADL as to self care, bed
mobility and transfer.
Ambulation: Min. Assist
Functional analysis:
FIM LEVELS
No Helper
7- Complete independence
6- Moderate independence
5- Minimal independence (subject 100%)
4- Modified dependence, Min. asst (75%)
3- Modified dependence, Mod. Asst (50%)
2- Complete dependence, Max. Asst (25%)
1- Complete dependence, Total Asst (less than 25%)
ADL

GRADE

Mobility
Bed mobility
Chair mobility
Transfer
Locomotion
Gait

6
7
6
7

Sitting/ Standing Balance Tolerance

Balanc
e
Sitting

Toleranc
e
(mins.)
Optimu

Standin

m
10 min

Legend:

Assume

Maintai

Weight

Challeng

-Shift

g
F
G

+
+

+
+

ASSESSMENT
PT Impression:
Pt. is a 23 y/o female and was diagnosed c Torn medial meniscus of
the (L) knee; S/P arthrotomy with medial menisectomy on (L) knee Pt.
has difficulty in doing in ADL such as ambulating 2 - L hip flexion,
hip extension & knee flexion d/t pain felt during flexion of hip and the
is a LOM
Procedural Intervention:
Pt. proposes a restorative intervention c 4 Tx session/wk for ~2mos.
Rehabilitation Prognosis: Pt. has good prognosis d/t supportive
family.

Problem List:

STG: (4 Tx Session)

LTG: (16 Tx session)

1. deep
nagging
pain on (L) knee
over the joint line
with PS 10/10

To decrease pain
on (R) knee over
the joint line from
PS 10/10 7/10
within 2 weeks

To eliminate pain on
(L) knee within the
end of the TX session

2. (+) Grade 2
tenderness on (L)
knee

To
decrease
grade
2
tenderness
to
grade 1 on (L)
knee with in 2
weeks

To
eliminate
grade
2
tenderness on (L)
knee
At the end of the
tx session

To increase ROM
of the (L) knee
with
5
increments with
in 2 weeks

To attain normal
or near normal
ROM of the (L)
knee At the end
of the tx session

3. LOM on (L) knee

4. (+) swelling on
(L) knee

To
decrease
swelling on (L)
knee 2 weeks

To
eliminate
swelling on (L)
knee At the end
of the tx session

5. Mod difficulty in
ADLs such as
ambulating

to perform Min.
difficulty
ADL
such
as
ambulating with
in 2 weeks

to perform ADLs
such
as
ambulating
without
any
hindrance with in
4 weeks

PLAN
PT Mx:
1. HMP/TENS x 20 mins on (L) knee
2. IRR x 20 mins on (L) knee
3. Proteection,Rest, Icing, Compression,an elevation on the (L)knee
4. PROME x 7 reps x 3 sets on all planes of the (L) knee
5. Patellar mobilization on (L) knee
6. Straight leg raises x 10 reps x 3 sets on both extremities