INITIAL EVALUATION

DEMOGRAPHICS:
Name: JImenez, Walter Date of IE: 09/04/2019
Age: 32 y.o. Date of Admission: OP
Sex: ♂ Room #: OP
Address: Block E Accretion Area Macablan, CDO Referring MD: Dr. Punsalan

Birthdate: 01/04/1987 Date of Referral: 08/30/2019

Nationality: Filipino Physiatrist: Dr. Barba

Civil Status: Married Dx: S/P IM nailing right femur; S/P ORIF plating
Occupation: left fibula; OR screw fix chain left medial
Religion: Roman Catholic malleoli
Handedness: R Medications: Vitamin ED-C Plus od, Calcium od

/S/:
C/C: Pt c/o gnawing pain on R LE when prolonged extension; also c/o pain when bending the
knee rated as 4/10 on NPRS (0 = no pain; 10 = greatest pain) relieved when treated c ointment.
HPI: Pt stated last 07/20/2019 around 5:20 am when they were on their way to Pagadian with
his co-workers driving an elf vehicle, he volunteered to drive in exchange of his sleepy co-
worker who was driving when they reached Lanao. As they go on, near Tigoma, a motorcyle
was approaching from the other lane, pt signaled to left turn when suddenly the motorcycle
u-turned in front of the elf which panicked the pt that caused the crash of the elf vehicle. Pt
and company survived while the motorcycle driver was dead. They were rushed to Mendero
hospital emergency room where pt underwent laboratory tests such as CT scan & X-ray. Pt was
for surgery and underwent abdominal surgery performed by Dr Lucero and ORIF performed by
Dr. Punsalan on the same day 07/23/2019. Pt was immobilized c a cast for 2 weeks and was
D/C last 08/09/2019. Pt stayed at relative’s home in Pagadian and had follow up check up c Dr.
Punsalan last 08/30/2019 where he was referred to have PT rehab session.
Pt. Goals: To be able to amb indep s the use of B axillary crutches
Prior level of function: Pt is able to amb indep s the use of B axillary crutches
Functional Status/Activity Level: Pt uses B axillary crutches when amb in household &
community
Social Hx: Pt lives c his wife, three children, uncle, employees and two students he sponsored
for education.
Employment/Work Status: Pt works as a “pelding” of rice, 3x/week.
Living Environment: Pt lives in a 2-storey hous c 8 steps going to the bedroom
General Health Status: Pt’s general health status is fair; no other major life changes other than
current condition in the past year.
Social Health Habits: Pt used to play basketball a the accident; pt drinks occasionally only
Family Health Hx:
Disease Maternal Paternal Pt.

CA (-) (-) (-)

DM (-) (-) (-)

HTN (-) (-) (-)

Stroke (-) (-) (-)

Tuberculosis (+) (-) (-)

Osteoarthritis (-) (-) (-)

Pt.’s Medical/Surgical Hx: Pt was confined in Mendero Hospital last 07/20/2019; had an
abdominal surgery & ORIF last 07/23/2019. Pt was D/C last 08/09/2019.

Other Clinical Tests:

Test Date Result
CT Scan 07/20/2019 To follow
X-Ray 07/20/2019 Fracture on right femur and left medial
malleoli
Meds:
Name: Dosage: Indication:
Vitamin ED-C Plus One tablet/od Necessary for the growth,
development and repair of all body
tissues.
Calcium One tablet/od Helping bone and teeth formation
and to maintain strength
/O/:
OI: Pt is mesomorph. (+) B axillary crutches, (+) surgical scar on R lateral thigh (24cm), L medial
malleoli side (7.8cm), L fibula side (13cm)
SYSTEMS REVIEW:
Cardiovascular / Pulmonary System:
a Rx p Rx Location, method, position
BP 128/91 134/88 R Brachial Artery, Auscultatory, Sitting
PR: 96 99 R Index finger, pulse ox, sitting
SPO2: 99 98 R Index finger, pulse ox, sitting
Integumentary System: (+) surgical scar on R lateral thigh (24cm), L medial malleoli side
(7.8cm), L fibula side (13cm), abdomen (20cm)
Musculoskeletal System:
Gross Symmetry: Impaired
Gross ROM: Impaired on B ankle
Gross Strength: Impaired on B ankle
Neuromuscular System:
Gait: Impaired
Locomotion: Impaired
Balance: Impaired
Motor Function: Impaired
Communication: Age-appropriate, unimpaired
Affect: Emotional & behavioral responses are unimpaired; pt. is fully engaged and responsive
Cognition: Pt. is oriented x3 as to PPT (person, place, time)
Learning Barriers: Pt. denies any learning barriers; (-) glasses, (-) contact lenses, (-) hearing aids
Learning Style: Pt learns best when given demonstration & rationale of the exercise.
Educational Needs: Proper weight bearing,
TESTS AND MEASURES:
ROM:
Joint: Normal: Active: Difference: Passive: Difference: End-feel:
R ankle 0-50⁰ 0-26 24 0-36 14 Firm
plantarflexion
R ankle 0-20⁰ 0-14 6 0-18 2 Firm
dorsiflexion
L ankle 0-50⁰ 0-25 25 0-28 22 Firm
plantarflexion
L dorsiflexion 0-20⁰ 0-13 7 0-15 5 Firm
Significance: Pt has ↓ ROM on B ankle plantarflexion & dorsiflexion due to tightness 2⁰ to
immobilization S/P ORIF plating left fibula.
MMT: All major muscle groups were assessed and determined to be WNL, except the following:
L R
Ankle plantarflexors 3-/5 3-/5
Ankle dorsiflexors 3-/5 3-/5

Legend:
5 = Completes available ROM against gravity c max resistance
4 = Completes available ROM against gravity c mod resistance
3+ = Completes available ROM against gravity c slight resistance
3 = Completes available ROM against gravity
3- = More than 50% of available ROM against gravity
2+ = Less than 50% of available ROM against gravity or complete ROM in gravity eliminated position c slight resistance
2 = Complete ROM in gravity eliminated position
2- = Incomplete ROM in gravity eliminated position
1 = Visible & palpable contraction but no motion
0 = no muscle contraction

Significance: Pt has ↓ muscle strength on B ankle plantarflexors & dorsiflexors due to tightness
2⁰ to immobilization S/P ORIF plating left fibula
Sensation: Pt has 100% intact sensation as to pin prick, light touch & dull pressure. Sensory
testing device: pin prick for pain, camel brush of reflex hammer for light touch, dull end of
reflex hammer for dull pressure.
DTR:
R L

Legend:
0 Areflexive
+ Hyporeflexive
++ Normoreflexive
+++ Hyperreflexive
++++ Clonus
N/A Not assessed
Significance: Pt is normoreflexive.
Balance/Tolerance:
Balance Tolerance
Sitting Normal Good
Standing Poor Poor Plus
Walking Poor Poor Plus

Balance Legend: Tolerance Legend:

Normal Maintain balance s support, max challenge Good >60mins
Good Maintain balance s support, mod challenge Fair+ 45-60mins
Fair Maintain balance s support, min challenge Fair- 30-45mins
Poor Requires support Poor+ 15-30mins
Significance: Pt has poor standing & walking in balance and poor plus in tolerance.
Poor- <15mins
Findings: Unable to stand indep s using axillary crutches
Gait Assessment:
PHASES OF GAIT R L
STANCE PHASE
Heel strike ↑ ↑
Foot flat ↑ ↑
Midstance ↑ ↑
Heel off ↓ ↑
Toe off ↓ ↑
SWING PHASE
Acceleration ↓ ↑
Midswing ↓ ↑
Deceleration ↓ ↑
Arm swing
Significance:Pt has ↓ heel off to deceleration on the R side.
Findings: Unable to walk indep s the use of axillary crutches; pt presents c PWB (50%) on L LE
ADLs:
 Ambulation: Pt is dependent c the use of B axillary crutches in household & community
amb
Transfers: Pt is dependent c the use of B axillary crutches when transferring from one
place to another
Dressing: Pt is indep in dressing UE & LE
Eating: Pt is indep in eating
Personal Hygiene: Pt is indep in taking a bath
/A/
Problem List:
1. Difficulty in household & community amb; (+) B axillary crutches
2. ↓ ROM on B ankle plantarflexion & dorsiflexion
3. ↓ muscle strength on B ankle plantarflexors & dorsiflexors
4. ↓ B/T in standing & walking
5. Gnawing pain during prolonged extension of LE
Therapy Dx: Pt has difficulty in household & community amb due to ↓ ROM on B ankle
plantarflexion & dorsiflexion, ↓ muscle strength on B ankle plantarflexors & dorsiflexors,
gnawing pain aggravated when prolonged extension of LE. Pt will benefit from electrical
stimulation for muscle facilitation, ergobike on B UE & LE to ↑ local endurance, AAROME to
AROME on B LE to maintain joint integrity and isometric exercises to ↑ muscle strength.
Practice Pattern: Musculoskeletal Pattern G: Impaired Joint Mobility, Muscle Performance and
Range of Motion Associated with Fracture
Prognosis: Pt has good rehab potential; pt is alert & cooperative all throughout rehab session

/P/
EO:
1. Pt will achieve near normal ROM on B ankle plantarflexion & dorsiflexion p 4 weeks of
PT rehab session to be able to amb in household & community s B axillary crutches
2. Pt will achieve near normal muscle grade on B ankle plantarflexors & dorsiflexors p 4
weeks of PT rehab session to be able to walk s difficulty
3. Pt will achieve normal in balance & good in tolerance in standing & walking p 4 weeks of
PT rehab sessions to be able to tolerate prolonged walking
AG:
 1. Pt will achieve an ↑ ROM on B ankle plantarflexion & dorsiflexion c an increments of 10⁰
p 2 weeks of PT rehab session to be able to amb indep s B axilary crutches around the
community & household
2. Pt will achieve an ↑ muscle strength from grade 3-/5→ grade 3+/5 on B ankle
plantarflexors & dorsiflexors p 2 weeks of PT rehab session in preparation for amb training
3. Pt will achieve normal in balance & good in tolerance in standing & walking p 4 weeks of
PT rehab sessions in preparation for parallel bar exercises

IP: Pt. will be seen as an OP 3x/week (MWF 1:00-2:00PM)c the ff. PT mx:
1. Ergobike on B UE & LE x 15 mins
2. Tall wind x 30 reps x 1 set
3. ES on B gluts, L gastrocs & tibialis anterior x 15 mins
4. Isometric exercises on L gastrocs & tibialis anterior c 6 secs hold x 10 reps
5. AROMEs on L LE towards all planes of motion x 10 reps
PT Suggestions:
1. Stretching on B ankle plantarflexion & dorsiflexion c 30 secs hold. X 1 rep
Precautions:
1. BP monitoring
2. Falls
Nichole Faye C. Abrasaldo
CDU PT INTERN 2020