SUBJECTIVE

 Patient is 54yo male referred to physical therapy with a diagnosis of Parkinson’s Disease. PMH
includes orthostatic hypotension, and myocardial infarction 3 years ago. He is taking Carbidopa-
Levadopa to manage his PD symptoms and takes this every 6 hours. Also takes midodrine to
manage his blood pressure. The patient was diagnosed 4 years ago with initial symptoms of a R
hand tremor and micrographia. The patient also reports difficulty typing which is causing
difficulty at work, now having to type largely with his L hand only. He is having difficulty
manipulating zippers, buttons, and small objects. He will sometimes need his spouse to assist
with dressing if the buttons are very small. Over the past year or so, symptoms have progressed
to a RLE tremor as well. The patient reports that his walking has slowed and he occasionally
catches his toe on the stairs when ascending. He denies having sustained any falls. His wife has
also taken over a lot of the household chores. He is able to help with some of the yardwork such
as mowing the lawn on a riding mower, but has difficulty raking leaves or using the
weedwhacker. He is still able to drive. He does feel stiff after he’s been sitting for a long time
and takes a few minutes of walking around to loosen up. The patient lives in a 2-story home
with his spouse. There are 3 steps to enter the home with a railing on either side. His place of
employment also has stairs to encounter. His goals for PT are to prevent worsening of his
condition, walk better, and improve his ability to dress on his own.

 OBJECTIVE

o Observation
 Posture is mildly forward flexed at the hip in standing with reduced lumbar
lordosis
 Resting tremor observed on the RUE
o AROM:
 Ankle dorsiflexion is 5 degrees B. Hip extension is 10 degrees B. Hip ER is 30
degrees on the R and 45 degrees on the L. All other LE AROM is WNL.
 Shoulder flexion is 140 degrees on the R and 160 degrees on the L. Wrist
extension is 15 degrees on the R and 25 degrees on the L. All other shoulder,
elbow, wrist AROM is WNL.
o PROM:
 PROM is WNL in all planes of the UE and LE
o Joint Mobility
 No hypomobility appreciated
o Strength:
 MMT of glute medius is 4/5 on the R, glute max is 3+/5 on the R.
 All other MMT of the hips, knees, and ankles is 5/5 bilaterally.
 MMT of shoulder ER is 4/5 B
 All other MMT of the shoulder, elbow and wrist is 5/5 bilaterally.
o Neurological:
 Absent clonus and Babinski
 Dermatomes are intact to light touch at L2-S2 bilaterally
  Myotomes are intact and strong at L2-S1 bilaterally (tested in sitting)
 Coordination reduced on the RUE with finger opposition and in the RLE with
heel to shin
 There is leadpipe rigidity in the elbow on the R
 Reflexes 3+ at the patella on the R. All others 2+
o Gait:
 Patient ambulates with no AD. Demonstrates decreased step/stride length with
minor shuffling on directional changes.
 Stairs are reciprocal with use of handrail. There is some hesitation ascending on
the RLE.
 Gait speed 1.0 m/s
 No overt unsteadiness demonstrated.
o Special Tests:
 Retropulsive Pull Test: 2
 Functional Gait Assessment: 21/30
 5x Sit to Stand: 14 seconds
ICF COMPONENTS:

Health Condition 1.

Body Functions and Structures 1.

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Activity Limitations 1.
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Participation Restrictions 1.
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Environmental Factors 1.
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Personal Factors 1.
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