SOUTHEAST ASIAN COLLEGE INC.

No. 2 E. Rodriguez Sr. Ave., Quezon City

COLLEGE OF PHYSICAL THERAPY

INITIAL EVALUATION

GENERAL INFORMATION referred the pt to PT REHAB for further evaluation and

management.
Pt’s Initials: R.S
Age: 48
Sex: M Laboratory and Ancillary procedures
Address: Nueva Ecija
Date Performed Findings
Civil Status: Married
Handedness: R
Occupation: Welder R knee x-ray June 13, 2019 (+) Posible osteophyte
BMI: formation
Referring Unit: PGH Rehab Unit (+) slight Joint space
Referring Dr.: Dr. V narrowing
Rehab Unit: PT Department
Rehab Dr.: Dr. C Joint Fluid June 13, 2019 3.5mL volume
Date of Referral: June 13, 2019 Examination Clarity: Transparent
Date of Consultation: June 15, 2019 Color: Clear
Date of IE: 06/15/19 WBC: 200 per mcL
Diagnosis: R Knee Osteoarthritis Polymorphonucluear
leukocytes: 25%
HPI: Culture: negative
Patient’s condition started 7 years PTIE when the pt jumped
from roof of the first floor. the next morning after waking up he ESR June 13, 2019 (-) Inflammation
felt pain (PS 7/10) on his R knee and it was swollen. pt 19 mm/hr
consulted her wife about his condition that the pt needs a
"manghihilot" to lessen the pain and swollen knee. 3 days after
Present Medications:
it was healed. that night the pt eats "papaitan" and drink beer c
Dosage/frequency Indication
friends. the next morning upon waking up the pt felt pain (PS
Benazepril 20 mg/ od Control HTN
8/10) on his r knee, again it was swollen. the pt decided to do
the same treatment thinking that it will lessen the pain and Arcoxia 70 mg/ od Pain reliever
swelling. 3 days after pain and swelling is still there. one of pt's
PS 8/10
friend saw the pt condition and suggested a medicine arcoxia
thinking that the swelling is due to arthritis and the pt decided
to take the arcoxia that night, pain and swelling was lessen the
next morning. For 1 year pt takes arcoxia everytime he felt the
PMHx
same pain and swelling on his R knee.
(+) HTN controlled since 2011
(+) Obesity 31.09 BMI
~6 years PTIE the pt go to the other country and becomes ofw,
(+) Trauma 7 years ago
for 5 years the pt stated that he did not feel anything abnormal
(-) Fracture
on his R knee.
(-) RA
(-) DM
~1 year PTIE the pt decided to stop working abroad and
(-) Osteoporosis
continue his welding services in the philippines. The pt goes
(-) CA
back to his old lifestyle causing him pain and swelling again.
The patient ignores the pain because arcoxia lessen the pain
FMHx
and swelling. Until 2 months the pt felt dull aching pain (PS
5/10) on his R knee due to 1 hour standing while doing MATERNAL PATERNAL
welding. Because of tolerable pain the pt take alaxan and rest
to lessen pain. The pt also stated that he’ll feel pain (PS 4/10) OA + -
whenever he walks to cock fight arena for 15mins and take a
rest for 5mins while massaging his R knee. pt ignores the pain Htn + -
because resting and massaging his R knee alleviates the pain.
(PS 1/10) RA - -

~1 month PTIE pt felt stiffness on his R knee for 20 mins p DM - -

waking up in the morning (PS 7/10) he took pain reliever
alaxan and massage the painful area, pain was partially Osteoporosis - -
relieved to (PS 1/10).
CA - -
~4 days PTIE The pt’s wife was worried about the pt's
condition so she convince the pt to consult doctor. From then
the pt decided to consult MD since he is also worried about his PSEHx
worsening condition and decided to have a healthier lifestyle. Pt is emotionally expressive and less stressed and considered
MD requested the ancillary procedure (see ancillary to be a Type B personality.
procedure) and dianosed the pt c Gr. 1 R knee OA. MD Sedentary lifestyle
Cigarette smoker for 3pack years
1
Alcoholic beverage drinker (occasionally) 2 bottles of beer (-) subluxation
Hobby is watching and playing cockfight (-) dislocation
Diet: (-) Joint effusion
- Vegetables and Meat (-) Inflammation
Lives with Wife, 1 son and 1 daughter
Always at home because of work ROM
Does not do house hold chores and always at the working All major joints motion of (B) UE and LE, including the neck
station and trunk were actively and passively assessed and were
found to be WNL, pain free and c normal end feels except:
motion AROM PROM Normal Diffe End-feel
 Home Situation renc
Patients live in a bungalow type of house. All rooms are e
well-lit, well-ventilated c tiled-flooring and s obstructions.
Uses Bedroom 1 and always at the living room when have R knee 0- 0- 0- 15de empty
free time from work. flexion 120deg 135deg 135deg. g.
In reference to the main door, the measurements are the . .
ff:
- Living room: ~3 steps R knee 125deg 135deg 135deg. 10de empty
- Bathroom: ~20 steps extension .-0 .-0 -0 g.
- Kitchen: ~20 steps
- Dining Room: ~20 steps Findings: LOM of R Knee Flexion and Extension
- Bedroom 1: ~5 steps
- Bedroom 2: ~10 steps Significance: LOM secondary to pain

 Work Situation MMT

- Has been working as welder for 20 yrs All major muscle groups of (B) UE/LE were assessed using
- Works at home break test and were found to be graded 5/5 WNL except:
- Main door to the working station is 6 footsteps
R Knee Flexor 5/ 0-120
SUBJECTIVE R Knee Extensor 5/ 120 knee flexion – 10 knee extension
c/o: “Sumasakit yung kanang tuhod ko kapag matagal ng
nakatayo at naglalakad (PS 7/10). Masakit at hindi ko rin Significance: Pt. has 5/5 muscle strength on all major muscle
maigalaw ito tuwing gigising sa umaga (PS 7/10). Napansin ko group WNL except R knee Flexion and Extension.
ring Sumasakit at namamaga ito kapag kumain ako ng mga
matatabang pagkain, munggo at sitaw.” (PS 8/10) . Superficial sensory A:
PT Translation: Pt c/o dull aching pain (PS 7/10) upon walking All sensations cold, hot, pain, and pressure were tested on R
~15 mins and standing for 1 hour. Pt also c/o of dull aching and L anterior thigh and knee and was found to be all 100%
pain and stiffness p waking up c PS 7/10 on his R knee. Pt c/o intact.
of dull aching and swelling on his R knee every after eating
fatty foods c (PS 8/10) Pain alleviates thru pain relievers and Findings: All sensations tested are normal.
massage (PS 0/10). Significance: For baseline purposes; Modalities may be used
Pt’s Goal: “Gusto ko ng mawala tong sakit na nararamdaman on Pt.
ko tuwing naglalakad, nakatayo ng matagal, pag gigising sa
umaga at magkaroon ng healthier lifestyle.” ANTHROPOMETRIC MEASUREMENT
Pt. was assessed in supine position. The measurements taken
OBJECTIVE were taken using a standard tape measure without physical
Vital Signs barriers (i.e. clothing) in both thighs and legs.
BP: 120/80 mmhg True Leg Length
PR: 82 bpm Landmarks L R difference
RR: 18 cpm
Temp: 36.8 deg. C ASIS to 92 cm 91 cm 1cm
Findings: All VS are WNL medial
Significance: For baseline Purposes malleolus

OI Apparent Leg Length

Ambulatory without assists Landmarks L R difference
Oriented x 3
Endomorph Umbilicus to 95 cm 94 cm 1cm
Alert, Coherent, and Cooperative medial
(+) Postural Deviation (See postural A.) malleolus
(+) Gait deviation (See gait A.)
(-) Swelling Findings: WNL
(-) Deformities Significance: No significant findings were noted. The Pt does
(-) mm atrophy not have leg length discrepancy which is a probable cause of
the condition.
PALPATION
Normothermic on (B) UE and LE Body Mass Index (BMI)
Normotonic on (B) UE/LE BMI = wt / ht^2
(+) painful crepitus on R knee flexion and extension = 92 kg / 1.71
(-) tenderness =31.5
2
Findings: Pt is obese.
Welding Pt presents modified independence as
Significance: Pt’s weight contributes to the severity of the
manifested by not being able to tolerate 1
condition. Pt may need to lose weight
hour of standing while welding d/t pain. Pt
rest for 5 mins and massage the R knee to
SPECIAL TESTS
relieve the pain.
Test Result Significance

Mcmurray test (-) snap or click Pt. does not have WOMAC
(-) pain meniscal pathology WOMAC Osteoarthritis Index:
of the knee
RESPONSE POINTS

None 0
Postural Assessment:
Anterior Posterior Lateral Slight 1

· Iliac crests level · Iliac crests level · PSIS higher Moderate 2

· ASIS level · PSIS level than ASIS
· Patellae facing · Popliteal folds · Slightly inc Severe 3
anteriorly, level level lumbar lordosis
· B LE in neutral · B LE in neutral · (R) knee Extreme 4
rotation rotation slightly flexed
· Tibial tubercle · Calcanei level
level · (-) Genu
· Medial malleoli valgum/varum PAIN
level
· Lateral malleoli Walking 2
level
· (-) Genu Stair climbing 0
valgum/varum
Findings: R knee slightly flex on lateral view Nocturnal 0
Significance: Postural deviation d/t pain and joint stiffness of
the R Knee.
Rest 0
Gait A:
Pt was assessed while amb on a leveled surface s any use of Weight bearing 1
ADs using pt’s desired speed.
R L
STIFFNESS
Stance Initial Contact (↓) Initial Contact (↑)
Phase Loading Response (↓) Loading Response (↑)
Midstance (↓) Midstance (↑) Morning stiffness 2
Terminal Stance(↓) Terminal Stance(↑)
Preswing Preswing Stiffness occurring later in the 1
Swing Initial Swing (+) Initial Swing (-) day
Phase Midswing (+) Midswing (-)
Terminal Swing (+) Terminal Swing(-) PHYSICAL FUNCTION
Findings: Patient present c shorter stance phase of the R LE
from loading response to terminal stance, shorter swing phase
Descending stairs 0
of the L LE from initial swing to terminal swing.
Significance: Patient presents antalgic gait
Ascending stairs 0
ADL ASSESSMENT
Pt is able to perform all ADLs such as self-care, bed mobility,
and transfers independently except: Rising from sitting 2
Ambulation Pt is able to walk independently s ADs
however presents difficulty d/t pain
Standing 2
manifested by increased time of completion
for the stance and swing phase of the ®
and (L) LE. Pt does not report knee locking Bending to floor 1
or “giving way”.

Transitions:: Sit Pt presents c modified independence as Walking on flat 1

to stand manifested by shifting his weight slightly on
his (L) LE then propping her hands on his
knees when standing in order to use her UE Getting in or out of car 0
to push up, assisting her LE in propelling
himself up.
Going shopping 2

3
 Putting on socks 1 PT Mx
Pt. will be seen and treated for 2x/week for 4 weeks

Rising from bed 2 1. HMP on R knee x 20 minutes to decrease pain and muscle
relaxation
2. AROMEs of R knees towards flexion and extension x 10
Taking off socks 1 reps x 3 sets to maintain muscle and joint integrity
3. Joint mobilization Grade III distraction x 6 secs stretch x 3
mins to increase joint play
Lying in bed 0
4. Resistance Exercise using Thera band towards flexion and
extension at the pain free range x 10 reps x3 sets to inc.
Sitting 0 muscle strength of the quadriceps and hamstring muscles.
5. Wall half squats x 10 reps x 1 set to improve activation of
quadriceps and hamstring muscles.
Getting in/out of bath 1
6. sit – walk – sit x 20 mins to improve muscle endurance and
neuromuscular control/strength
Getting on/off toilet 2 7. TENS on R knee x20 minutes to decrease pain

Heavy domestic duties 3 HEP

1. AROMEs of B LE towards all motions x 10 reps x 3
sets to maintain joint integrity
Light domestic duties 2 2. Self-stretching of B Hamstrings & Quadriceps using
towel x 30 SH x 5 reps
3. Mini-squats x 6 SH x 10 reps to maintain muscle
TOTAL SCORE: strength
● Pain: 3/20 4. Walking x 20minutes to improve physical conditioning
● Stiffness: 3/8
● Physical Function: 20/68
Findings: Pt has a low score Patient Education
Significance: Serves as a baseline for progression of pt’s 1. Inform pt about his condition, what to expect
condition as well as to monitor pt’s subjective response, as to regarding recovery
her daily function, to the treatment being provided. 2. Inform pt about the importance of alternating rest with
activity
ASSESSMENT 3. Inform pt about the importance of compliance to HEP
PT Dx: musculoskeletal Pattern D
4. Avoid too much weight bearing activities on B LE
PT Impression: MDx of Gr.1 R Knee Osteoarthritis further
defined as LOM on R knee Flexion and extension, Gait such as prolonged walking & standing
deviation, postural deviation, crepitus on ® knee during flexion 5. DO proper body mechanics on ALL exercises
and extension and pain. 6. Inform pt. About energy conservation techniques
a. RESPECT PAIN
PROBLEM LIST b. Avoid positions of deformity - keep knees
1. Pain on R knee upon walking and WB PS 7/10
straight in bed, weight bearing equally on B
2. LOM towards R knee extension and flexion
3. Decrease muscle strength on R Knee* feet
4. Antalgic Gait c. Avoid awkward positions
5. WOMAC total score: 26/ 96 d. Use large muscle groups
e. Use adaptive equipment - quadcane
LTG:
Diminished pain of the R knee
Maintain normal ROM
5/5 of muscle strength on R Knee References:
Attain WOMAC score of 0 Physical Rehabilitation – Sullivan
Normal Gait Deviation Therapeutic Exercise – Kisner
Physiopedia.com
STG: 4 weeks nhlbi.nih.gov
Dec. pain on R knee 7/10 – 3/10 Orthoinfo.org
Increase ROM on R Knee Orthopedia.com
Slight increase of muscle strength on R Knee
WOMAC Score 10
Normal Gait
Prepared By:
REHAB POTENTIAL: Good Cañeza, Mary Joy M.
Pt has a good rehab potential since Pt wants to have a healthy Sarmiento, Micahella Yvette C.
lifestyle. Pt’s family is supportive c pt’s rehab sessions. Pt will Southeast Asian College, 4th yr PT Student ’19-‘20
be able to shoulder all rehab expenses.

PLAN