Ryan Camp

Physical Therapy Evaluation / Plan of Care Form

Patient Information and Demographics:

Name: Paul Theo (prefers: Paul) Age: 62 Gender identification: Male

Date of Service: 10/21/20

Administrative Codes:
PT Diagnosis (ICD-10): M62.81 (muscle weakness R LE); R53.83 (generalized
fatigue); R26.81 (impaired balance)

Medical Diagnosis (ICD-10): G14 (post-polio syndrome)

Current Procedure Units Duration

Terminology (CPT) Billing
Codes
97161- Low Complexity Eval 1 60 minutes
Due to cardiac co-morbidity, could also be considered a moderate complexity

SUBJECTIVE:

CC / Reason for Referral:

Decreased aerobic endurance, dynamic standing balance, and muscle strength secondary to Post-polio
Syndrome.

Onset and Progression of symptoms:

Patient presents with a new diagnosis of post-polio syndrome that he received from his primary care
physician last week. Patient reports that he was diagnosed with polio when he was 7 years old when he
was traveling to Europe with his family. He states that he was not put on an iron lung, but instead was fit
with leg braces which he wore for a few years. By the time the patient was 12 years, his symptoms
stopped, and he was able to participate in “regular kid activities” such as bowling. Just recently within the
last year he started having symptoms once again. He reports that his primary symptoms include decreased
aerobic endurance and right lower leg. Additionally, the patient comments that his back has been hurting
lately. When questioned on his pain levels, the patient stated that his pain was currently 4/10 and 8/10 at its
worst on the VAS pain scale. The patient describes the pain as a pinching pain that periodically sends a
shooting pain down his back. He reports the pain to occur when he changes positions quickly, for example
when he stands up. Furthermore, the patient’s back pain is said to be reduced when he is in supine. The
patient reports that his symptoms have been affecting his ability to participate in his work activities as a 3rd
grade schoolteacher in Mt. Pleasant. He has difficulty with walking the kids to the cafeteria and back, as
well as standing for long periods to teach at the front of the class. The patient reports attending his first

Page 1 of 14
 Ryan Camp

PPS support group last Friday. Patient currently has his sub-lingual nitroglycerin on him and it is current.
Patient states that he has not used his sub-lingual nitroglycerin in years.

Previous Medical and Surgical History:

Polio at 7 years old.
Coronary artery graft x2 (5 years ago).
Right ACL repair (20 years ago).

Current Medications (list prior ones if relevant, e.g. steroid use; include OTC and supplements, add
columns if needed):

Medication Mechanism/Side Effects/Reason this Dose and Frequency

patient is taking
Nitroglycerin Vasodilation of smooth muscle in blood 0.4 mg SL Q5min x3 prn
vessels C.P.

Headache, dizziness, weakness,

tachycardia, nausea, vomiting, rash,
flushing.

Prevention of angina. Vasodilator

Coumadin Inhibiting the synthesis of vitamin K 2.5 mg daily P.O.
dependent clotting factors.

Serious bleeding, pain, swelling,

bruising, nosebleeds, dark urine, cough
up blood, bloody vomit, head ache,
dizziness/fainting, weakness, fatigue,
black/tarry stools, chest pain, SOB,
dysphagia

Treatment of blood clots/ blood thinner

Lipitor Inhibiting HMG-CoA reductase and 10 mg P.O @ h.s
cholesterol synthesis in the liver by
increasing the number of hepatic LDL
receptors.

Mild memory loss, confusion, increased

diabetes symptoms, rhabdomyolysis,
muscle pain, weakness, tenderness,
kidney dysfunction, liver dysfunction,
yellowing of skin, dark urine.

High cholesterol
Questran light Lowing LDL levels in the blood 1 scoop mixed in juice
BID P.O

Page 2 of 14
 Ryan Camp

Constipation, stomach pain, gas, nausea,

vomiting, unusual bleeding/bruising,
rapid breathing, confusion, rash,
swelling, dizziness, troubles breathing.

Lower cholesterol
Anaprox Inhibition of prostaglandin synthesis. 275 mg P.O TID prn

Upset stomach, nausea, heartburn,

headache, drowsiness, HBP, vision
changes, fatigue, sudden weight gain,
swelling, itching, trouble breathing.

Nonsteroidal anti-inflammatory
Ultram Inhibition of neuronal reuptake of 50 mg P.O Q6H prn
norepinephrine and serotonin

Nausea, vomiting, constipation,

lightheadedness, dizziness, fatigue,
interrupted breathing, agitation,
hallucinations, stomach pain, loss of
appetite, fainting.

Pain reduction for knee

Cozaar Blocking angiotensin II from binding 50 mg P.O QAM
and producing aldosterone
(vasoconstrictor)

Dizziness, lightheadedness, fainting,

weakness, slow/irregular heartbeat, rash,
breathing difficulty.

Lower blood pressure

Level of Activities Prior to Current Onset:

Patient participated in walking with his wife, walking his students to lunch, and performing recess duty at
the school without any limitation. Additionally, the patient participated for IADL’s/ADL’s without
difficulty or limitation.

Home /Work/ Other Relevant Environment(s): Nice description of home and work environment
Patient is a 3rd grade elementary school teacher in MT. pleasant. Patient comments that his classroom is
on the opposite side of the building from that cafeteria. He lives 4 blocks away from the school. He used to
walk to work, but has to drive the 4 bocks now. His house is 2 levels with his bedroom and bathroom on
the main level. The second level of the house consists of his children’s old bedrooms and an additional

Page 3 of 14
 Ryan Camp

bathroom. The building has 5 steps to enter the front door, with a railing on both sides. There are 12 steps
to second floor with a railing on the left side. Patient states that he doesn’t go up there unless cleaning
kids’ rooms or attic, which is “rare.” The patients house is fitted with carpet in the living room and
bedroom, tile in the kitchen, and wood floors throughout the remainder of the house. Patient has a tile
walk-in-shower with a step/obstacle to get in.

Psycho-social / Family Support / Family Responsibilities:

The patient has a wife who is 60 years old and retired. Additionally, the patient has 3 children. Two of his
kids live in Mt. Pleasant and work for an electrical company (30 and 32-year-old). The third son lives in
California and is 27 years old. His wife and two children living in Mt. Pleasant are available and willing to
help if needed during the patient’s rehabilitation process. Patient’s wife cooks dinner and does the
housework, while he is responsible for the yard work.

Relevant Dietary / Elimination Issues:

No dietary/elimination issues reported.

History of falls:
Patient reports no history of falls.

Client Goals:
The patient would like to have more energy at work, to walk for farther distances, stand at the front of the
class for longer periods of time, participate in recess duty, and take shorter breaks during yard work.
Additionally, the patient wants decreased back pain.

OBJECTIVE:

Position / Arm used BP Pulse RR

Sitting 120/80 52 14
Standing 128/84 56 16
After Exercise 132/82 72 18

Communication, Cognition, Orientation:

Patient is A&Ox4 (person, place, time and circumstance) and is cognitively unimpaired.

Cranial nerves and related

The patient does not present with any deficits that would indicate the need for in-depth cranial nerve
testing (ex: blurry vision, difficulty swallowing, impaired sense of smell, etc.). Instead, a cranial nerve
screen was utilized for this patient to pick up on any structures that might be affected due to the post-polio
syndrome.

Test Nerve/system Comments

Smell (Olfaction) Intact, normal
Visual Acuity (near, far) Intact, normal Snellen and Rosembaum is 20/20

Page 4 of 14
 Ryan Camp

Visual fields Intact, normal Both superior and inferior visual fields are normal
bilaterally
Visual Tracking (pursuits) Intact, normal No nystagmus
Sensation Face Intact, normal
Jaw muscles strength Intact, normal
Face Muscles (asymmetry) Intact, normal
Rinne’s or/and Weber’s for Intact, normal
hearing
VOR Test Intact, normal No nystagmus
Gag reflex Intact, normal
Tongue Movement Intact, normal Symmetrical protrusion, normal deviation.
Sternocleidomastoid / upper Intact, normal 5/5 strength
traps

Reflexes:
Reflex Right Left Remarks
Ankle jerk 2+ 2+ Normal
Quadriceps 2+ 2+ Normal
Brachioradialis 2+ 2+ Normal
Biceps 2+ 2+ Normal
Triceps 2+ 2+ Normal
Plantar reflex Present, normal Present, normal No Babinski bilaterally
Clonus Absent, normal Absent, normal No clonus bilaterally

ROM, Strength, Tone

ROM/Strength ROM/Strength Comments:

RIGHT LEFT
PROM MMT PROM Strength PROM/AROM was WNL
AROM AROM Grade throughout bilateral UE/LE.
WNL Shoulder Flexion WNL
WNL Shoulder Extension WNL Patient MMT: UE/LE= 5/5
WNL Shoulder Abduction WNL bilaterally throughout with
WNL Shoulder Int. Rotation WNL exceptions shown to the left
WNL Shoulder Ext. WNL
Rotation
WNL Elbow Flexion WNL
WNL Elbow Extension WNL
WNL Wrist Flexion WNL
WNL Wrist Extension WNL
WNL Trunk-Extensors WNL
Muscle Tone:
WNL Trunk-Abdominal WNL
Patient was not found to have
WNL 4+ Hip Flexion WNL

Page 5 of 14
 Ryan Camp

WNL 4+ Hip Extension WNL abnormal tone.

WNL 4+ Hip Abduction WNL
WNL 4+ Hip Adduction WNL
WNL 4+ Hip Internal Rotation WNL
WNL 4+ Hip External Rotation WNL
WNL 4+ Knee Flexion WNL
WNL 4+ Knee Extension WNL
WNL 3+ Ankle Dorsiflexion WNL Movement Patterns:
WNL 4+ Ankle Plantarflexion WNL n/a

Co-ordination:
Test Right Left Remarks
Finger to Nose Normal Normal
Heel to Shin Normal Normal
Pronation/ supination Normal Normal
Alternating Normal Normal
dorsiflexion/plantarflexion

Sensation:

Right Upper Extremity Left Upper Extremity

Sharp/Dull Intact, normal Intact, normal
Proprioception Intact, normal Intact, normal
Light Touch Intact, normal Intact, normal
Vibration Intact, normal Intact, normal
Hot/cold discrimination Intact, normal Intact, normal
Right Lower Extremity Left Lower Extremity
Sharp/dull Intact, normal Intact, normal
Joint position sense Intact, normal Intact, normal
Light Touch Intact, normal Intact, normal
Vibration Intact, normal Intact, normal
Hot/cold discrimination Intact, normal Intact, normal

Bed Mobility and Transfers.

Task Assistance Devices Description
Nice descriptions here

Rolling Independent n/a Patient shows a lack of trunk rotation in the thoracic and
lumbar spine throughout.
Scooting in Independent n/a No difficulty
Bed
Supine to sit Independent n/a Patient shifts weight to his left side, assumes jack-knife
position, and uses hands to sit up. Grimace face observed
when patient-initiated movement from supine.
Sit to supine Independent n/a Patient shifts his weight to his left side and lowers himself

Page 6 of 14
 Ryan Camp

down with bilaterally UE’s. Eccentric motion appears

controlled throughout.
Sit to stand Independent n/a Patient uses both arms to stand up.
Stand to Sit Independent n/a Eccentric movement is controlled throughout. Patient uses
hands to sit down.
Bed to chair Independent n/a Patient again uses hands to guide himself into chair.
transfer
Floor Independent n/a Patient arises from the ground with his left knee on the
Transfer ground, and his R LE flexed to 90° at hip/knee. The
patient then shifts his weight forward and to the left while
using his hands to push himself up into a squatting
position. From there he stands normally.

Posture:
Patient sits with a slightly kyphotic back, forward head, and slightly rounded shoulders. Eye contact is
maintained throughout entire visit. Patient rests his hands on his lap throughout the visit. Patient is stable
and has no excessive sway in the seated position.

Patient stands with as narrow BOS, kyphotic back, forward head, and slightly rounded shoulders. Upon
initial sit to stand the patient has no excessive sway and appears steady in static standing.

Balance:
The patient’s static and dynamic sitting balance is normal and unaffected. Additionally, the patient’s static
standing balance appears normal. The patients dynamic standing balance seems to be affected. When a
perturbation is provided and the patient sternum, he uses multiple steps to regain balance and holds his
arms out in front of himself as 45° of shoulder flexion. Only with very small perturbations, the patient is
able to utilize appropriate ankle strategies. Abnormal hip/stepping strategies are used in response to small-
large perturbations.

Gait/Locomotion: Excellent description. I can visualize this gait.

The patient walks with a slight forward head posture, kyphotic back, and rounded shoulders. The patient
has increases stance phase on left (unaffected) lower extremity. Additionally, the patient has unequal step
length with the right side being shorter than the left. The patient seems to have normal arm swing
throughout gait. Patients feet adequately clear the floor throughout swing phase. Patient effectively shifts
his weight during stance phase. During swing phase, the patients swing leg passes just to the side of the
stance leg. Patient appears to have proper walking stability and ambulates independently. However, as
patient is nearing approximately the 160 ft mark, he begins to have labored breathing and decreased
aerobic endurance.

Subtask Distance Level of Devices Descriptions

assistance used
Gait indoors 150+ Independent n/a above

Steps 12 Independent N/a Patient utilizes left handrail. When cued,

patient removes their hand from handrail

Page 7 of 14
 Ryan Camp

without difficulty.

Functional Independence Measure Scores:

Activity Score NA = Not Applicable (does not occur)

Transfers: 7, NT = Not Tested (mention why)
independent 1 = Total Assistance (0-24%)
2 = Maximal Assistance (25% - 49%)
Gait: 7, 3 = Moderate Assistance (50% - 74%)
independent 4 = Minimal Assistance (75% - 100%)
5 = Supervision or Set-up (safety concern / takes more than reasonable
Stairs: 6, pt uses time)
handrail 6 = Modified Independence (assistive device)
7 = Complete Independence
RULE for GAIT (and W/C): distance modifies the scoring as follows:
3 = to get this or higher must go 150 feet or greater
2 = 50 to 149 feet (see household exception)
1 = less than 50 feet
Household Exception rule: Client who can walk 50 feet independently
with or without a device can get a 5
RULE for STEPS:
3 = to get this or higher must go 12 – 14 steps
2 = 4 to 6 (or less than 12)
1 = less than 4 steps
Household Exception rule: Client who do 4 – 6 steps independently with
or without a device can get a 5

Standardized Tests Used:

Test Score Interpretation / Rationale

Tinetti 23/28 Increased risk of falling. Patient struggles with: arising from chair w/o hands,
Balance small perturbations in standing, and step symmetry during gait.
Assessment
Activity 66.25/100 Patient has low balance efficacy with ADL’s/IADLs and functional tasks in
Specific both dynamic and static balance positions. Patient is least confident with
Balance walking tasks, especially in the community.
Confidence
Scale
(ABC)
Fatigue 54/63 Patient reports a high level of fatigue that interferes with his daily life,
Severity family, job, etc.
Scale (FSS) Thank you for utilizing the FSS! It's very appropriate for this patient!

Today’s Interventions (must include consent to treat):

Page 8 of 14
 Ryan Camp

After the patient was educated on what tests and measures would be used, informed consent was obtained.
The patient was made aware of their right to refuse all, or any part of the evaluation. Goals were made
with the help of the patient. The goal of today’s session was to complete an evaluation and thus no
treatment was provided

ASSESMENT: Nice assessment

The patient has the following impartments: decreased aerobic endurance levels, decreased R LE muscle
strength, impaired stance phase in gait, unequal stride length, decreased dynamic standing balance, and
decreased ability to transfer/transition (especially from supine to sit, and from floor transfer)

Due to the above impairments, the patient has difficulty participating in his job as a 3rd grade
schoolteacher, as well as walking with his wife. Additionally, the patient appears to be at an increased risk
of falling due to his initial impaired dynamic standing balance. For all of these reasons, the patient is a
great candidate for physical therapy, and could benefit from training in the following areas: gait training,
balance, strengthening, and endurance. The patient would also benefit from an education on the
importance to exercise for increasing aerobic endurance and overall health.

Precautions:
Patient has a history of cardiac surgery/complications which requires him to carry a sub-lingual
nitroglycerin tablet. Vitals need to be monitored before, during, and after exercise to ensure patient safety.

Rehabilitation Prognosis:
Patient is a good candidate for PT and has promising rehab potential. Additionally, the patient seems
motivated to participate which will serve him well throughout this rehabilitation process. With a quality
HEP, education, and physical therapy the patient will likely make improvements in his overall strength,
endurance, gait, and balance. With proper management, the patient’s symptoms can be reduced, and he
can make improvements in function.

GOALS:
Short (3 weeks)
1. Patient will exercise at an intensity of 70% HRR for a period of 15 minutes (total) to demonstrate
an increase in aerobic endurance necessary for the patient to walk his patients to lunch.
2. The patient will walk 200 feet without reporting fatigue in order to walk with his wife to get the
mail.
3. The patient will educate the PT on previously described fatigue management skills (such as
chunking tasks/ workouts) in order to demonstrate that he understands the importance of splitting
up motor tasks to reduce the risk of fatigue and injury.
4. Patient will demonstrate that he can write on the “chalkboard” (wall) for 5 minutes with a narrow
BOS without the LOB in order to demonstrate improved dynamic balance/ endurance necessary to
work as a teacher.

Page 9 of 14
 Ryan Camp

Well-written goals!

Long (6 weeks)
1. Patient will exercise at an intensity of 75% HRR for a period of 30 minutes (total) to demonstrate
an increase in aerobic endurance necessary for the patient to work recess duty at his school.
2. The patient will walk 4 city blocks without reporting fatigue in order to walk with his wife on the
weekends.
3. Patient will demonstrate that he can write on the “chalkboard” (wall) for 15 minutes with a narrow
BOS without the LOB in order to demonstrate improved dynamic balance/ endurance necessary to
work as a teacher.
4. The patient will demonstrate that he is able to ascend and descend 12 stairs without the assistance
of a handrail so he can walk up to the second floor of his house and back down without LOB and
fatigue.

PLAN:
Patient will be seen for physical therapy 2x/week for 6 weeks. Treatment will include neuromuscular re-
education (balance, coordination, posture, etc.), gait training (level and unlevel surfaces, stair climbing),
therapeutic exercise (strength and cardiovascular training), and patient education (ex: on exercises he can
do at home). The patient will be sent home with a HEP after his next visit. Will track progress over future
visits and re-evaluate at the end of the 3rd week.

I certify / recertify that the above therapy services are necessary, and I agree with the plan of care above.

Physician Name/Signature
Date

Therapist Name/Signature
Ryan Camp, SPT

Date: 10/21/20

Page 10 of 14
 Ryan Camp

Durable Medical Equipment Recommendation

 This patient has normal sitting/standing static balance. Additionally, the patient has only minor gait
deficits which includes unequal step length and increased L LE stance phase. Other problems that
the patient is experiencing is R LE weakness and decreased aerobic endurance. The patient also
has impaired dynamic standing balance. Due to these impairments a straight cane or walking stick
would be recommended to the patient. A straight cane will assist the patient with dynamic balance
in standing and during gait. Since the only significant impairment that the patient is experiencing is
decreased aerobic endurance, all other DME is deemed unnecessary (ex: walker, crutches, WC).
YES! It would be
Additionally, the patient does not have any ROM or strength problems that would require the hard to justify
patient to need an orthosis for gait. A walking stick may also be less stigmatizing for the patient something more
based on your
when they need to use it in the community. findings!

Page 11 of 14
 Ryan Camp

Page 12 of 14
 Ryan Camp

Page 13 of 14
 Ryan Camp

Page 14 of 14