INITIAL EVALUATION

GENERAL INFORMATION
Patient’s name: Jessie Reyes
Age: 47 y/o
Sex: Male
Address: Antipolo street, Tondo, Manila
Civil status: Married
Handedness: ®
Occupation: Physical Education Instructor
Referring Unit: University of the East Ramon Magsaysay Medical Center
Rehab Unit: Saint Joseph Phsyical Therapy and Rehabilitation Center
Referring MD: N/A
Rehab MD: N/A
Date of referral: June 2017
Date of PT consultation: June 2017
Date of IE: October 4, 2018
Diagnosis: S/P Right ACL reconstruction surgery

HPI
Present condition started ~26 years ago PTIE, when pt was playing basketball, pt suddenly
experienced twisting sensation on the ® knee with no pain. But pt. ignored it and continued
playing. Pt. continued on all aspects of ADL without pain and difficulty for the next ~25 years.
~1 year and 6 months ago PTIE, pt. undergone X-Ray and the result showed full ACL injury on
the ® knee. The pt. had ACL reconstruction surgery at University of the East Ramon Magsaysay
Medical Center.
~1 year and 5 months and 2 weeks ago PTIE, pt. experienced sharp aching pain (P/S 10/10) at the
® knee after surgery and had severe difficulty in ADL as to LE activities as to ambulation, LE
dressing and undressing, stair ascending and descending and other LE activites. Pt. went back to
UERMMC and doctor diagnosed infection of the (R) knee upon inspection and laboratory exams
(unrecalled) and prescribed Tramadol for the pain via IV injection and administered every 4 hours
or whenever pain came back. (P/S 10/10→4/10)
~1 year and 4 months ago PTIE, the pain subsided into P/S 1/10 and pt. scar healed and he went
back for a follow up check up at UERMMC. The pt. was referred for Physical Therapy for further
evaluation and rehabilitation.
At present, pt. is undergoing Physical Therapy and is independent in all aspects of ADL without
difficulty except ambulation, stair descending, and ascending with minimal difficulty.

COORDINATION A:
* EQUILIBRIUM TESTS
Grading
4 - Able to accomplish activity
3 - Can complete activity; minor physical contact guarding required maintaining balance
2 - Can compete activity; significant (moderate to maximal) contact guarding required to maintain
balance
1 - Activity impossible
ACTIVITY GRADE
Standing: feet together 4
Walk: place heel of one foot in front of toe of 4
the opposite foot
Walk: on toes 3

Note: Non-equilibrium test wasn't done d/t (-) neurological deficit

Findings: All tests performed have normal coordination except: walk on toes which requires minor
physical guarding to maintain balance.
Significance: 2° (R) ACL injury

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JEWEL MAY P. LUI
UDM PRE-INTERN BATCH 2019

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KRISTOFFER IVAN J. MILAN
UDM PRE-INTERN BATCH 2019