LORMA COLLEGES

INITIAL EVALUATION

GENERAL INFORMATION

Patients Name: C.R

Age: 75 y/o
Sex: M
Address: San Fernando City, La Union
Civil Status: Married
Handedness: Right
Occupation: None
Religion: Roman Catholic
Referring Unit: Walk in
Referring Dr: N/A
Rehab Dr: Dr. C.R
Date of Referral: N/A
Date of Consultation: October 17, 2016
Date of Evaluation: October 18, 2016
Diagnosis: (R) knee OA
S:

C/C: Masakit ang tuhod ko, di ako makapaglakad

HPI: Present condition started 2 yrs. ago prior to PTIE p pt. went for a long time walking,
pt. felt intermittent deep nagging pain c PS 6/10 on (R) Knee upon walking or prolonged
standing (~10min). Pt. states that pain is being alleviated to PS 1/10 at rest, and putting
pillow below the knee during lying down and is being aggravated when in cold
temperature. Once a yr., pt. takes steroid injection (not specified) on his (R) knee for pain
relief to PS 3/10 even during in a cold environment. Pt. has difficulty in doing in ADL such
as dressing and ambulating 2 to difficulty in (R) knee flexion and hip flexion d/t pain felt
during flexion of hip and knee of (R) LE.

PMHx: Pt. was diagnosed to have (+) Brain Tumor (1997). Pt. has also history of
medical intervention and surgical procedure. (+) Thyroid Gland Surgery (2013), (+) DM
Borderline.

FMHx:

Mother Father
HTN (-) (-)
DM (-) (-)
Heart Dse. (-) (-)

PSHx: Pt. has an active lifestyle and exercises regularly. Pt. has no hx of substance
abuse, a non-smoker and a non-alcohilic drinker. Pt. lives in a 2-storey concrete house.
States that Bedroom Comfort Room distance is ~10 steps; Bedroom Dining Room
~20 steps; Bedroom Garage ~ 20 steps; Bedroom Living Room ~10 steps. Pt. is
helping on doing household chores, however, p pain was felt on his (R) knee. pt. then
experienced difficulty on performing ADLs.

Pts Goal: Sana mawala na yung sakit maayos yung paglakad ko

O:

VS: BP = 130/80 mmHg

PR = 81 bpm
RR = 19 cpm
Temp. = 36.8C

OI: Manner of arrival: W/C Bound

Mental status: Alert/Coherent/Cooperative
Physique: Ectomorph
Swelling: (+) swelling on (R) knee
Atrophy: (+) atrophy on (R) Quadriceps and Gastrocnemius
Skin Trophic Changes: (-)
Attachment: (-) attachment

Palpation:
Tone assessment: Normotonic on all exposed areas except for hypotonia on
LE
Thermal assessment: Normothermic on all exposed areas except for
hyperthermia on knee
Tenderness: (+) Gr.1 Tenderness on knee
Muscle Tightness: (-)
Edema: (-)

Neurologic Examination:
Sensory Testing
Device used: pin for pain, brush for light touch, thumb for P
Findings: 75% intact sensation on LE
Sig: 25% diminished sensation on LE
DTR:

Legend:
0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

Findings: Pt. is normoreflexive on (B) UE/LE except for (R) knee

Sig: Pt.s refusal 20 to pain and swelling.

ROM:

Findings: All jts. Of B UE, LE are actively and passively done c normal end feel
except:

JOINT AROM PROM NORMAL DIFFERENCE ENDFEEL

(R) Knee 0-110 0-118 0-135 Active Passive EMPTY
Flexion 70 62

(R) Hip 0-105 0-110 0-120 15 10 FIRM

Flexion

Sig: Limited ROM on (R) Knee Flexion and (R) Hip Flexion 20 pain.
MMT:
Findings: All major (m) of B UE/LE are graded 5/5 except for: (R) LE graded
3+/5
L R
Knee extensors 4/5 3+/5
Hip flexors 4/5 3+/5

Sig: m weakness on (R) Knee extensors and (R) Hip flexors 2 to immobility

ST: Pt. refused to perform test.

FA:

Functional Analysis:
ADLs FIM LEVELS
Self-care No Helper
Feeding: 6 7 - Complete Ind.
Grooming: 4 6 - Mod Ind.
Dressing: 4 5 - Min Ind. (subject 100%)
Bathing: 6 4 - Modified Dep, Min. Asst (75%)
Toileting: 6 3 - Modified Dep, Mod. Asst (50%)
Bed mobility 2 - Complete Dep, Max Asst (25%)
Roll to right: N/A 1 - Complete Dep, Total Asst (<25%)
Roll to left: 4
Supine to sit: 4
Sit to supine: 4
Transfer
Bed to chair: 4
Sit to stand: 4
w/c to toilet: 4
Ambulation: N/A
 Sitting/ Standing Balance Tolerance
Balanc Toleranc Legend: Assume Maintain Weight Challeng
e e (mins.)
-Shift e
Sitting G Optimum 0 - - - -
Standin F 10 min P + - - -
g
F + + - -
G + + + -
N + + + +

A:

PT Impression: Pt. is a 75 y/o male and was diagnosed c (R) knee OA. Pt. has
difficulty in doing in ADL such as dressing and ambulating 2 to difficulty in (R) knee
flexion and hip flexion d/t pain felt during flexion of hip and knee of (R) LE.
Procedural Intervention: Pt. proposes a compensatory intervention
Rehabilitation Prognosis: Pt. has poor prognosis d/t old age.
Pt. Prognosis: Pt. has poor prognosis. Pt. is irritated when complying on his PT Mx.

Problem List:
Problem List
1. Intermittent deep nagging
pain on (R) knee c PS of 6/10
2. Muscle weakness on (R)
Knee extensors and (R) Hip
flexors
LTG ( 12Tx STG (6 Tx Sessions)
Sessions)
Pt. will state pain free To pain on (R) knee
feeling on his (R) from PS 6/10 to 3/10
Knee within 3 Tx sessions.
Pt. will achieve N Pt. will achieve 4/5
muscle strength p 6 MMT Grade on on
weeks (R) Knee extensors
and (R) Hip flexors p
8 Tx sessions
 3. Limited ROM on (R) Knee
Flexion and (R) Hip Flexion
4. Difficulty on performing
ADLs such as dressing and
ambulating
Pt. will achieve N or Pt. will attain ROM
near N ROM within 10 by 5 increments in
wks. 2wks.
To attain at least min. To attain min transfer
assist on bed mob and assist p 8 Tx
transfer p 10 wks. sessions

P:
PT Mx:
1. HMP c TENS on (R) knee x 20
2. US x 1.5 w/cm2 x 5 on SA
3. FES on (R) LE x 20
4. (R) leg ex x 20reps c 2.5 lbs ankle weights
5. Isometric ex on quads & hams 7SH x 5reps
6. Patellar mob

Suggested Mx:
1. Education on suggested Mx to help pt. perform exercises at home.
2. AAROM on (R) Knee x 15

JALBUNA, JUDY FE D. /BSPT-IV___

Students Name and Signature