Adventist Medical Center Manila

Initial Evaluation
(Feb 18, 2020)

GENERAL INFORMATION:

Name: Carmelita De Castro

Age: 69 years old
Gender: Female
Address: Makati City
Occupation: Business Manager
Civil Status: Married
Nationality: Filipino
Religion: Catholic
Referring Unit: Lynette Chua-Villa Clinic
Referring Dr.: Dr. Lynette Chua-Villa
Rehab Unit: AMCM Physical Therapy Rehab
Rehab Dr.: Dr. Gan
Date of referral: Feb 15, 2020
Date of consultation: Feb 15, 2020
Date of IE: Feb 18, 2020
Diagnosis: ® Hip OA

S:

C/C: “masakit yung sa right hip ko when I am sitting and walking for long period of time, yung sakit na parang
hihiwalay na yung thigh ko sa legs (PS8-9/10) kaya there are times I cannot concentrate at work, I just took pain
reliever whenever I cannot bear the pain. ”

PT Translation: pt c/o intermittent localized dull aching pain (PS8-9/10) on ® hip elicited upon prolonged sitting and
walking that leads her to moderate difficulty concentrating at work and relieve when taking medicine.

Pt’s Goal: “gusto ko na mawala yung sakit ng ® hip ko and walk without depending on my cane at times para hindi
nako hirap sa mga gusto kong gawin sa bahay like cooking and sa work ko where I sit for long time”

PT Translation: pt would like to eliminate pain on ® hip and walk without depending on cane at times so she can do
her work properly and ADLs like cooking.

HPI:

Initial condition started when patient was at work sitting for long period of time. Patient then felt intermittent
localized dull aching pain (PS 8-9/10) on her ® hip elicited upon prolonged sitting that leads her moderate to severe
difficulty doing her job and even ambulating. Even at home, patient still felt the same so she took pain reliever and
had her bed rest.
 Feb 15, 2020 patient went to clinic to have her condition checked up with her husband; test was done,
ancillary procedure was also requested (see ancillary procedure), doctor prescribed her medicine to take (See
Present Medications) and patient was then diagnosed with ® hip OA and was then referred to Physical therapy right
after.
At present, patient started her PT treatment last Feb 18, 2020

ANCILLARY PROCEDURES:

PROCEDURE PLACE TAKEN DATE TAKEN RESULTS

x-ray of ® hip Feb 12, 2020 *to follow

PRESENT MEDICATIONS:

DRUG NAME DOSAGE/FREQUENCY INDICATION

Meloxicam 50mg/qd Pain reliever
Genacol collagen plus glucosamine bid
Aprobel qd For treatment of high blood pressure
Concore Qd Heart dse

PMHx:

 (+) HTN (controlled since)

Highest BP: 200/100 mmHg, (N) BP: 110-120/80-70mmHg
 (+) heart disease
 (+) spine operation 3 yrs ago (metal implant)
 (-) DM
 (-) pneumonia

FMHx:

Disease Paternal Maternal

HTN (-) (+)
DM (-) (-)
Heart Disease (-) (+)
Pneumonia (-) (+)
Arthritis (-) (+)

PSEHx:

Personal & Social:

 Personality type: type A personality
 Lifestyle: sedentary
 Diet: milk, biscuit for breakfast, rice and pork
 Hobbies: reading books, cleaning house
Home Environment:
 Lives a 2 storey house c her husband and daughter
 2 flight of stairs, 12 steps on 1st flight, 13 steps on 2nd flight
 Distance from main door ↔ bedroom = 50 steps
 Distance from main door ↔ CR = 45 steps
 Distance from main door ↔ kitchen = 35 steps

Work/Business Set Up:

 Work: Business manager
 Patient sits at ordinary office chair c back rest
 Office hours: 8am-5pm
 Sit and stand situation for long period of time in work place

O:

VS

a P
BP 120/70 mmHg 140/70 mmHg
PR 61 bpm 61 bpm
RR 18 cpm 19 cpm
T° 36.3°c 35.8°c
Findings: pt’s VS are WNL except ↑ BP after treatment
Significance: pt has HTN; pt’s VS will serve for monitoring and baseline purposes

OI:

Amb c cane on (L) hand

Alert, coherent, cooperative
Oriented x3
Mesomorph
(+) surgical scar on midline of lower back
(+) Postural Dev (See PA)
(+) Gait Dev (See GA)
(-) atrophy on (B) UE/LE
(-) erythema on (B) UE/LE
(-) inflammation on (B) UE/LE
(-) swelling on (B) UE/LE
(-) wounds on (B) UE/LE
(-) skin discoloration on (B) UE/LE
(-) skin tropic changes on (B) UE/LE
(-) bruises on (B) UE/LE

PALPATION:
Normothermic on (B) LE and lumbar area
normotonic on (B) lumbar area
(+) non painful crepitus on (B) LE
(+) nodules on (B) lumbar area
 (+) tautbands on (B) lumbar area
(+) mm spasm on (B) lumbar area
(+) muscle tightness on (B) LE
(-) mm guarding on (B) LE
(-) contractures on (B) LE
(-) tenderness on (B) LE

ROM:
All major joints of the body were actively and possibly assessed and found to be WNL, pain-free and have (N) end-
feel except for the ff:
(N) value AROM PROM AROM DIFF. PROM DIFF. END FEEL
®HIP 0-120 0-110 0-120 10 0 SOFT
FLEXION
SLR
(L) HIP 0-120 100 105 20 15 SOFT
FLEXION
SLR
FINDINGS: pt presents decrease ROM on hip SLR Flexion on (L)
SIGNIFICANCE: this might affect pt’s ADL such as standing while cooking; treatment should include AROMEs
exercises, walking and ascending and descending stairs.

MMT:
All major mm groups of (B) LE were grossly assessed and found to be WNL except:
MM groups Grade
(L) hip flexors 4/5
® hip flexors 3/5
(L) hip extensors 4/5
® hip extensors 3/5
FINDINGS: pt’s (L) LE showed good muscle strength while ® LE showed fair muscle strength
SIGNIFICANCE: pt has decreased strength on hip flexion and extension; this will affect pt’s ADL such as
walking. Pt will also have difficulty maintaining posture.

Leg Length Discrepancy:

(L) ®
From umbilicus to mid malleolus 83.5cm 82cm
From ASIS to mid malleolus 85cm 83cm
FINDINGS: pt presents LLD on ® LE
SIGNIFICANCE: this may d/t pain

Postural Analysis:
Anterior View Lateral View Posterior View
Head Slight forward head Level
Mandible Level Retracted -
Shoulders Uneven Retracted
Pelvis Anterior tilt Anterior tilt Anterior tilt
Hips Anteversion
Knees Level
Ankle

FINDINGS: pt has postural deviation

SIGIFICANCE: weak muscles in back and hip. Pt may have moderate difficulty when picking up objects. Tx
should include stretching and strengthening exercises on (B) LE

GAIT ANALYSIS:
(N) HIP KNEE ANKLE
HS 30 flexion/ 20 flexion (N) (N)
neutral/ neutral
FF 20 flexion/5-15 15 flexion 10 flexion (N)
flexion/15 PF
MS Neutral/ 5-15 (N) 10 flexion (N)
flexion/ 10 PF
HO 10-20 15 flexion 5 flexion (N)
hyperextend/ 5
flexion/ neutral
TO Neutral/neutral/ (N) (N) 10 flexion
20 DF
ACC. 20-30 flexion/ 30 flexion 35 flexion Neutral
40 flexion/ 10
PF-neutral
MS /60 flexion-max 20 flexion 60 flexion neutral
knee extension/
neutral
DEC. /30 flexion- 10 neutral 30 flexion Neutral
neutral/neutral
FINDINGS: pt has decrease in FF, HO of (B) HIP & knee
SIGNIFICANCE: pt presents gait deviation that may affect ADLs such as walking. This may also d/t pt’s
weak muscles in LE and pain upon prolonged walking and sitting. Mx may include gait training exercises
and educate pt on proper gait training with cane.

ADL ANALYSIS:
Patient is independent in all aspects of ADLs s any difficulty except for moderate difficulty in
walking, and standing alone.
A:

PT Impression: Pt is a 69 year old female who was medically diagnosed c ® hip OA defined as
degenerative changes in articular cartilage that causes moderate difficulty in doing ADLs, manifested by
weakness in (L) LE and moderate difficulty performing ADLs such as walking and sitting from home to work
place, decrease range of motion and muscle strength on ® LE, (+) Leg length discrepancy on ® LE, (+)
postural deviation & gait deviation.

Rehab Potential: Pt has GOOD prognosis d/t: pt’s initiative in coming c her treatment sessions and was
cooperative all throughout, pt’s house is near in the Hospital while her family support emotionally and
spiritually is given. Pt is financially stable with support.

Pt has FAIR prognosis d/t: pt’s age, pt has other co morbid illness aside from HTN and was done spine
operation 3 years ago that may affect pt’s present illness.

PRECAUTION: Burn, fall, fracture

PROBLEM LIST:
1. LOM on (R) hip flexion
2. Decrease muscle strength (B) LE specifically hip flexors
3. Nodules on (L) lumbar area and (L) gastrocs
4. Taut bands on (L) lumbar area and (L) gastrocs
5. Mm spasm on (L) lumbar area and (L) gastrocs
6. Postural deviation
7. Gait deviation

LTG: (2 Months)
1. To be able to increase range of motion LE flexors by 10-20° increments
2. To be able to increase muscle strength of LE muscles from 3/5 to 5/5
3. To be able to eliminate nodules, taut bands and muscle spasm.
STG: (1 Month)
1. To be able to increase ROM of hip flexion on (B) LE by 5-10° increments
2. To be able to increase muscle strength of hip flexor from 3/5 to 4/5
3. To be able to decrease nodules, taut bands and muscle spasm

P:
1. HMP c TENS on ® hip x 20’
2. US on ® hip x1.5w/cm2 x 3mHx x 5’
3. Light PREs on (B) LE using SAW x AP x 10 reps x 1 set
4. AROME Exercises:
a. hip extension in prone position x 10 reps x 1 set
 b. hip flexion and abduction in supine position x 10 reps x 1 set
5. // Bar Exercises
a. Step up and down on foot stool x 10 reps x 1 set
b. Side steps on foot stool x 10 reps x 1 set
c. Leg curls x 10 reps x 1 set
6. Gait training Exercise x 1 round
HEP:
1. Ambulatory c cane on (R) hand
2. Stretching exercises of (R) LE x 30 SH x 3 reps
3. AROMEs of (B) UE/LE 10 reps x 3 sets
4. Heel/toe raises x 10 reps each

Suggestions:

1. Lumbar stabilization exercise

a. Bent leg lift to 90° x 10 reps x 1 set
b. Heel slide to extend knee x 10 reps x 1 set
c. Straight-leg lift to 45° x 10 reps x 1 set

PREPARED BY:

Avellana, Janelle Anne B.

Cayanan, Karina
Velasquez, Aerohn