PATIENT EVALUATION FORM

IDENTIFYING DATA:
NAME: Ismael Amistoso
HANDEDNESS: (R) handed
AGE: 80 y.o.
MD: Dr. Condor
ADDRESS: L TudtudMabolo, Cebu City
August 14, 2015
SEX: Male
PHYSIATRIST: Dr. Elda Grace Anota
NATIONALITY: Filipino
CONSULTATION: September 3, 2015
CIVIL STATUS: Married
Total Hip Replacement
OCCUPATION: Former LTO employee
EVALUATION: September 8, 2015
RELIGION: Roman Catholic

REFERRING
DATE OF REFERRAL:

DATE OF
DX: S/P (L)
DATE OF
MEDS:

Tramadol HCL, Paracetamol (for pain)

Cefuroxineaxetil (antibiotic)
Celecoxib (anti-inflammatory)

HPN
RA
CA
DM
Asthma
Cardiac
dss

Pt.
(+)
(-)
(+)
(-)
(-)
(+)

Maternal
(+)
(-)
(-)
(-)
(-)
(-)

Paternal
(+)
(-)
(-)
(-)
(-)
(-)

/S/:

C/C: Pt. C/o intermittent, localized, aching pain @ (L)

hip with an in intensity of 5/10 on a VAPS (0=no pain,
5=moderate pain 10=worst possible pain); aggravated
by movement and relieved by rest

HPI:
August 10, 2015
- Pt was on his way to his mini office across South
Bus Terminal together with his friend @ around
4pm. Upon crossing the street, a fast moving van overtook the motorcycle and hit him. He landed
on his (L) hip
- Pt stated that the van driver didnt see him crossing the street
- Pts friend brought him to Chong Hua Hospital; attended by Dr. Barbas
- Pt underwent x-rays and laboratory test and found out he had fracture on his (L) hip
August 14, 2015
- Pt underwent THR on (L) hip 20 fracture with the order of Dr. Condor
August 15-19, 2015
- Pt. had few sessions of PTR sessions inside the hospital
August 20, 2015
- Pt was discharged from hospital
September 3, 2015
- Pt was referred to PTR @ ARC PSH by Dr. Elda Anota
September 8, 2015
- Pt started 1st PT treatment session
PMH:
July 2012
- Pt was operated for his gall bladder
HFD: