INITIAL EVALUATION
Patients Name:
F.B
Age:
73 y/o
Sex:
Male
Address:
San Fernando, La Union
Civil Status:
Married
Handedness:
(R)
Occupation:
retired nurse
Religion:
Roman Catholic
Referring Dr.:
Dr. R
Referring Unit:
OPD
Rehab Dr.:
Dr. P
Date of Referral:
August ,2016
Date of Consultation:
August ,2016
Date of Eval:
Jan 20 , 2016
Diagnosis:
(L) hip OA- elective total hip replacement
S:
C/C: sumsakit yung kanang hita ko ps 6/10 , napapansin ko ding nahihirapan
na akong maglakad at tumayo sa kama
C/O: Radiating constant pain extended down from the front of his thigh c
a PS of 6/10 (using VAS). Pt. notice that she has difficulty in walking and stand on
the bed
HPI:
Present condition started 6 mos. PTIE when pt. felt increasing pain c a
(PS 6/10) in his hip and noticed he was having difficulty walking and getting
out of bed. Pt. asked medical advice to Dr. R and he was diagnosed with severe
left hip joint degeneration related to osteoarthritis. Dr. R suggested that pt.
undergo an elective total hip replacement. Pt.s reported that on arrival to the
post op pt. was placed in a semi-Fowlers position with an abduction pillow
between his legs. Pt. states that he was drowsy and oxygenated through a
facemask. Pt. states that she was asleep during the operation. Pt. was transferred
to the surgical ward after a 60 minute stay in OR. P 2hours after pt.s return to
the ward he was observed to be in pain, reported his pain score as 5/10 and was
distressed and restless. Pt. relieve the pain by taking Oral OxyContin 10mg
BD.The following day p the operation. Pt was referred for PT treatment
(unrecalled) stated his pain was much improved.
At present, pt.s pain was decreased to PS 3/10 but was afraid stand up by
her own.
PMHx:
(+) HPN (celecoxib, 400 mg, BID)
(+) heart Dse
(+ Unrecalled
(-) DM
FMHx:
F
Cancer
DM
Heart Dse
PSHx:
M
(+)
(-)
(-)
(-)
(-)
(-)
Pt. is a non smoker and a non-alcoholic beverage drinker and not
abusing any substance. Pt. lives in a 2-storey building with his wife, daughter and
son-in-law. Main door to Living room: 3 steps; Living room to Bed room: 12 steps;
Main door to Kitchen: 7 steps; Comfort room to Bed room: 6 steps. Pts room is
situated in the ground foor.
Goal:
kama ".
O:
"Gusto ko mawala na yung sakit at kahit papano makatayo ako sa
VS:
BP= 130/90mmHg
PR= 80 bpm
RR= 18 cpm
To= 37oC
OI:
Manner of arrival: Ambulatory c assistive device
Mental status: Alert/ Coherent/ Cooperative
Body type: Ectomorph
Trophic skin changes: (+) erythema on hip
Atrophy: (+) hamstring m & quads m
Postural deviation: (+) (see Postural analysis)
Attachment: (-)
PALPATION:
Thermal assessment: All body parts are normotermic except for a
hyperthermic on inguinal area.
Tone assessment: Normotonic on hip
Tenderness: (+) gr. II tenderness on groin area c dull, aching pain
when palpated
Muscle spasm: (+) d/t muscle guarding
Swelling: (+) on hip
Tightness: (+) on hip jt.
Edema (grade & type): (-)
ROM:
Findings: Motions of (B) UE/LE, neck and trunk were assessed actively,
and are WNL except for the ff:
Difference
Motions
AROM
PROM
(N)
AROM
PROM
Empty
10 o
7o
Empty
70 o
64 o
Empty
7o
5o
Endfeel
s
hip
0 20o
0 23o
30o
extension
hip
0-50 o
0-56 o
0-120
o
flexion
hip
0 38o
0 40o
0
45o
internal
rotation
hip
0-30 o
0-33 o
0-45 o
Empty
15 o
12 o
0 30o
0 35o
Empty
15 o
10 o
Empty
12 o
10 o
external
rotation
hip
45o
abduction
hip
0 18o
0 20o
0
30o
adduction
Sig: LOM 2o to pain
MMT:
Findings: All major (m) of (B) UE/LE were grossly graded 5/5 except for:
Muscles
hip extensors
Grade
3/5
hip flexors
3/5
hip abductors
3+/5
hip adductors
4/5
hip internal
4/5
rotators
hip external
3/5
rotators
Sig: (m) weakness 2o to inactivity
ST:
(+) Trendelenburgs sign
(-) Obers Test
Sig: 2o to pain on hip
NEUROLOGIC EVALUATION:
Sensory Testing
Devices Used: Pin for pain, brush for light touch and thumb for deep P
Findings: 100% Intact sensation
Sig: Intact sensory pathway
DTR:
(L)
(R)
+
Legend: 0
areflexia
++
hyporeflexia
++
normoreflexia
+
+++ hyperreflexia
+
++++ clonus
Findings: Normoreflexive on (B) UE/LE
Sig: Intact reflex arc
ANTHROPOMETRIC MEASUREMENT:
Limb Girth Measurement:
Landmark
3
2
1
Patella
L
54cm
48cm
45cm
42cm
R
52cm
46cm
42cm
42cm
Sig: 2o to muscle atrophy
PA:
Findings:
Anterior View:
Sh. Is higher than (L) sh.
lat. curvature
(L) iliac crest is higher than the iliac crest
hip slightly adducted
knee is lower than (L) knee
genu valgum
foot pronation
Difference
2cm
2cm
3cm
0
Posterior View:
Sh. is higher than (L) sh.
scapular elevation (L) iliac crest is higher than the iliac crest
Lateral View:
head forward
sh. Elevation
GA:
Stance
Phase
IC
LR
MS
TS
Swing Phase
IS
MS
TS
(L)
(R)
+
+
+
+
(L)
+
+
+
_
_
_
_
(R)
Decrease
Decrease
Decrease
Sig: Antalgic gait on side of the body 2 o to pain
Functional Analysis:
ADLs
Self-care
Feeding
:5
Grooming
:6
Dressing
:4
Bathing
:4
Toileting
:4
Bed Mobility
Roll to right: 6
Roll to left : 7
Supine to sit: 5
Sit to supine: 6
Transfer
Bed to chair : 4
Sit to stand : 4
FIM LEVELS
No Helper
7- Complete independence
6- Moderate independence
5- Minimal independence (subject
100%)
4- Modified dependence, Min. Asst.
(75%)
3- Modified dependence, Mod.
Asst. (50%)
2- Complete dependence, Max.
Asst. (25%)
1- Complete dependence, Total
Asst. (less than 25%)
w/c to toilet : N/A
Ambulation
:4
Sitting/Standing Balance Tolerance: N/A
A:
.
PT Impression:
Pt. is a 73 y/o female has difficulty in self care, , bed
mobility and transfer(d/t pain on (R) hip 2o hip arthroplasty
Procedural Intervention: Compensatory Intervention
Rehabilitation Potential: Good d/t intermittent s/sx
Prognosis: Pt has a good prognosis that complies with PT Mx base on
rehabilitation potential and family support.
Problem list
1 Pain and
LTG (24tx session)
Pt will demonstrate
STG (12 tx session)
Pt. will report a pain
tenderness on his
proper body mechanics
on hip from 6/10-
R hip with PS 6/10
& observe proper
4/10 p 3 days of tx
posture to the
occurrence of pain p 3
wks
Pt will achieve near (N)
Pt will increase ROM
hip ext.,flex., int.
ROM on hip
by 3o increments on
rot, ext.
extension, internal
hip extension, internal
rot,abduction, &
rotation, abduction, &
rotation, abduction, &
adduction.
adduction within 5 wks
adduction p every tx
Pt will achieve optimum
session
Pt will increase (m)
hip extensors
(m) strength on (R) hip
strength by 5o
&flexors, internal&
extensors,flexors, int.
increments on (R) hip
external rotators,
rotators, ext
extension, internal
1. Limited ROM on
2. (m) weakness on
abductors&adduct
rotators,abductors &
rotation, & abduction
ors muscles
adductors within 5wks
p every tx session
Pt. will demonstrate (N)
Pt will report a diff.
difficulty in
functional act. w/n 5
in performing
performing
wks of tx.
functional activity
3. Pt. has max
functional
within 3 wks of tx
activities such as
session
walking, climbing
stairs, and sitting
4. Pt has mod
Patient will easily
Patient will easily
difficulty in
perform
perform
performing ADLs
ADLs(bathing,eating,do
ADLs(donning and
such as donning
ffing and donning) c no
doffing of pants &
and doffing of
difficulty w/n 4 wks of
socks, urinating &
pants & socks,
tx.
defecating) mod
urinating &
defecating
5. (+) Postural
deviation
min difficulty w/n 2
Pt will achieve (N)
wks of tx.
Pt will report a
posture & proper body
decrease postural
mechanics within 5 wks.
deviations & m
guarding within 3 wks
of tx.
P:
PT Mx:
Pt will be treated as an OPD for 24 tx session
1. US x 1.5 W/cm2 x 5x2x/wk on hip to pain and promote healing
2. PREsx2x/wk on LE c 1lb AWx10repsx1set AP to increase m
strength
3. Aquatic ex. x20 2x/wk for jt mobilization
4. Gait training inside // bars c obstacles x 5 rounds
5. Mini squat x5SHx10reps
Precaution:
BP
