Orthopedic chart

I. Subjective Data：
1. Name： 王萍 指導老師：沈怡屏
2. Age： 48y/o 報告學生：王詩予
3. Sex：女
4. Chart No：562037
5. Occupation：教會傳道人
6. Diagnosis：x-ray showed left tibia plateau fracture
7. Brief history：3/14 騎機車出車禍，3/15 在高醫開刀
8. Past history:無
9. Date of PT starting：2020/03/20 PT intervention /Treatment date:4/1
10. Chief complaint：從髖關節到踝關節肌肉瘀青，傷口疼痛，動大拇指會痛；
從膕窩痛到後腳跟
11. Patient’s goal：不用拐杖能走路上班
12. Medical image：X-ray
II. Objective data：
III.
1. Observation：大腿旁肌肉延伸到小腿肌肉瘀青
從坐到站需要手扶助行器站立
Posture:正面:手扶助行器，軀幹向前屈曲，骨盆重心偏向右側
側面:走路受傷腳會外轉，左腳偏向外側，身體偏右側
2. Palpation：開刀處附近腫脹皮膚發熱
A. Adhesion：沒有
B. Swelling：傷口縫線處腫脹
C. Skin color： 褐黃瘀青色
D. Tightness： Tensor fasciae latae m. Vastus intermedius .Tibialis
anterior
E. Scar：patella 左上 11cm patella 左下 10cm L`t knee 1cm
F. Circumference：(單位: cm)
Date 3/25 3/25
Left Right
Above knee joint line 15cm 40.5 41.5
Above knee joint line 10cm 39 40
Above knee joint line 5cm 39 38.5
 At knee joint line 37.5 37.5
Below knee joint line 5cm 36.5 33.5
Below knee joint line 10cm 34.5 33
Below knee joint line 15cm 31 29

3. Sensation：
Hip Knee Ankle
Light Touch + + +
Pin Pick + + +
Proprioception + + +

4. Pain condition：VSA:0~10
Rest 2~3
Motion 4~5
Aggressive 例如:Active shoulder flexion over 150°→175°and ER 85°, VAS：3→2
(Supraspinatus area) Active knee flexion over 90°→100°°, VAS：2→3

5. ROM(AROM/PROM/End feel)
Date 4/1
AROM PROM
Left Right Left Right
Hip flex 0~60 0~120 0~90 0~120
Hip ext. 0~10 0~20 0~10 0~20
Hip add 0~10 0~20 0~10 0~20
Hip abd 0~20 0~40 0~20 0~40
Hip ER 0~20 0~45 0~30 0~45
Hip IR 0~20 0~45 0~30 0~45
Knee flex 0~50 0~150 0~50 0~150
Ankle 0~10 0~20 0~10 0~20
dorsiflexion
Ankle 0~25 0~50 0~25 0~50
plantarflexion

6. MMT
Date 3/31
Left Right
 Hip flex 3 5
Knee flex 2 5
Ankle 3 3
dorsiflexion
Ankle
plantarflexion 0 4

7. STTT
Active Passive Resisted End-feel
Knee flex. + + + Firm
Knee ext. + + + Hard

8. Gait：
右腳可以承重左腳離地不承重，使用助行器走路
Stance phase Swing phase
Weight Single limb Swing limb advancement
acceptance support
IC LR MSt TSt PSw ISw MSw TSw
Trunk
Forward lean Offset
Right
Lateral lean:Right/left Right Right
Pelvis
Hikes
Hip
Flexion:limited
knee
Flexion:limited

Ankle
Forward lean Drop
feet
Excess plantar flexion

IV. Assessment
A. Problem List：
1. Swelling pain and foot pain cause
2. Can't climb stairs
3. Ankle Swell
4. Poor hip muscle strength insufficient
B. Short tern goal： ( 2 week)
1. Improve ankle dorsiflexion rom 10→20
2. Improve hip flexion rom 60→90
3.Ambulation endurance from 0→10 m
4. Swelling knee
5. Improve muscle strength: Quadriceps m.setting from 3→4 point
6. Improve muscle strength: Tibialis anterior strength
7. Improve muscle strength: Vastus intermedius strength
C. Long tern goal： ( 1 month)
Improve hip rom to 0→100
Improve ankle rom to 0→40
Improve up and down stairs 1F to 2F
She can walk to the kitchen with a walker(20 m)
She can use a walker from the room to the living room(10 m)
Plan：Quadriceps m.setting
1.purpose: Increase muscle strength
2.dosage (60 s/time 15 set/day)
Tens
1.purpose:Reduce pain and tens to relieve tight muscles
2.dosage : (15 Min/day)
Ankle pumping
1.purpose:Reduce edema and relieve muscle tension
2.dosage: (5 s/time 15 time/set)
Foot on the rolling ball
1.purpose:knee joint don't be stiff
2.dosage: (15 time/set 30 Min/day)
Walker
1.purpose: Improve ambulation strength
2.dosage: (15 time/set 30 Min/day)
Home program：
Using walker to assist in the transfer from wheelchair to bed
Using walking aid to assist in walking at home without hurting the feet
Ambulation training: 60 s/ under 30 times/day
Ankle pumping: 60 s/time 15set/day
Quadriceps m.setting: 60 s/time 15set/day