INITIAL EVALUATION

General Data

NAME: AB
AGE: 83 y/o
GENDER: M
MARITAL STATUS: Married
ADDRESS: Sitio Bayante, Pinagtung-ulan, San Jose, Batangas
OCCUPATION: Lawn Mower
RELIGION: Roman Catholic
NATIONALITY: Filipino
HANDEDNESS: Right
REFERRING PHYSICIAN: Dr. Villanueva
PHYSIATRIST:
DATE OF REFERRAL:
DATE OF CONSULTATION: May 31, 2016
DATE OF EVALUATION: August 12, 2017
TYPE OF PATIENT: Out-patient
DIAGNOSIS: Knee RA, B

S:
CHIEF COMPLAINT: “Masakit ang aking parehong tuhod (p.s 4/10), minsan din ay aking mga balikat, kamay at paa. Nahihirapan
akong maglakad at umupo na nakaka-apekto sa aking pagtatabas, pag gagamas at paglilinis ng aming bahay”

Pt’s GOAL: “Nais kong mabawasan ang sakit ng aking mga kasukasuan lalo na ang aking tuhod upang makaupo at makalakad ng
maayos at makatulong ako sa amin”

HPI:

2 days PTE, pt had acute attack of RA and experienced pain and swelling (p.s 6/10) on his B knees and difficulty in ambulation.
Pt had also fever, fatigue and loss of appetite. To relieve the pain, pt took Systocor 5 mg or Diclofenac Sodium Voren 50 mg which
decreases the pain.

At present, the pt still complains of aching pain and difficulty (p.s 4/10) on B knees after sitting for prolonged periods and
ambulation on elevated surfaces.

PMHx:
 (+) RA, B (2016) (Systocor 5 mg , Diclofenac Sodium Voren )
 (-) HTN
 (-) Cardiopulmo dse
 (-) DM
 Extra articular manifestations of RA
 (-) Falls

FHx:
 (+) RA , paternal

PSEHx:
 Elementary undergraduate
 Bungalow style house c entry steps
 Lives with his wife and 2 grandchildren ;
 Not a breadwinner of the family ; financially stable
 Alcohol drinker and non-smoker
 Type B personality
 Not willing to consult to PT
 Uses sickle for cutting grasses ~ 1 hour
 Helps out in the sari-sari store which is 13 m away from the house

O:
VS:
 BP: 120/80 mmHg
 PR: 78 bpm
 RR: 16 breaths per minute
 Temperature: 36.5 ºC

Interpretation: VS are WNL

Inspection:
 Alert, coherent, cooperative
 Ectomorph
 Ambulatory s AD
 (+) Forward head
 (+) Swelling of knees
 (+) Swelling on B elbows
 (+) Swan Neck deformity, B hands
 (+) Gait deviation (see Gait Assessment)
  (-) Swelling
 (-) Muscle Atrophy
 (-) Erythema
 (-) Skin lesions

Interpretation: Above finding shows that swelling of the knee is a common complication in mild knee RA

Palpation:
 Normothermic, B knees
 Normotonic
 (+) Nodules on B knees
 (+) Crepitus on B knees
 (+) Hamstring Tightness, B
 (+) Bony enlargement
 (-) Tenderness on B knees
 (-) Edema on B knees

Interpretation: Above findings shows that presence of nodules, crepitus and bony enlargement are manifestations of mild knee RA

Anthropometric Test

Muscle Bulk Test

Left Right Difference

7 in above lateral knee 31 cm 33 cm 2 cm
joint line
6 in below lateral knee 23 cm 27 cm 4 cm
joint line

Interpretation: Above findings shows that further muscle atrophy would be evident in Knee RA especially when it becomes
progressive or in advance

Significance: For baseline purposes

ROM:

Interpretation: Joints of BLE are WNL done passively and actively within pain-free
Pt is in the mild type of Knee RA. No contractures in the knee were noted

Significance: Contractures are common complications of RA

Muscle Length Testing

L R N
Hamstrings at 0-45º 0-50º 0-90 º
knee (90-90)
Rectus Femoris 0-45º 0-50º 0-135 º

Interpretation: Above findings shows that the muscles are short.

MMT: (Range Grading Test)

All muscles groups of BLE and crutch walking muscles are graded 5/5 except:

KNEE FLEXORS, B = 4/5

KNEE EXTENSORS, B = 3+/5

Interpretation: Above findings shows that there had been residual weakness from a recent acute attack of RA

Special Test:

 (+) Tripod test, B

 (-) Ely’s Test, B

Interpretation: Above findings confirms tightness of hamstrings

Significance: Tightness is a complication of knee RA

Neurologic Assessment:

Sensory Assessment

A. Superficial sensation

STD: Pin for pain, brush for light touch, blunt side of neurohammer for pressure

Findings: Intact sensation on B knees as to pain, light touch, and pressure.

DTR

Interpretation: There is no neurological involvement in mild knee RA

Significance: For tx purposes only

Postural Assessment:

No other pertinent findings

Gait Assessment:
 ↓ stride length = 82 cm
 ↓ step length = 41 cm
 ↓cadence = 85 steps/min
 ↓ gait speed = ~1.37 m/sec

Interpretation: Above findings interprets that age is a factor for decrease components of gait assessment

Functional Assessment

Interpretation: The above findings are common functional limitations d/t pain on B knees. Pt shows moderate to maximal difficulty in
walking on elevated surfaces after prolonged period. Pt experiences maximal difficulty in doing deep squats and when getting out of
bed. The result

A:

PT Impression: Pt has mild type of knee RA as confirmed with dull aching pain and swelling on B knees (p.s. 4/10), multiple nodules,
bony enlargements and morning stiffness ~ 2 hours. It was also confirmed by laboratory examinations: increased ESR, 44 U CCP and
17 IU/Ml RF and a WOMAC score of 51/96.

Rehab Potential: Pt has good prognosis since he has mild type of knee RA and d/t few sign and symptoms, complications and no
comorbidities associated c RA

Problem List:

1. Intermittent dull, aching pain (p.s. 4/10) that aggravated during knee flexion and extension
2. Weakness on B knee extensor = Gr. 3+
3. Moderate to maximal difficulty as to sit to stand transitional activity

P:

LTG:
1. Pt will be able to return to do lawn mowing c minimal difficulty
2. Prevent secondary impairments and progression of symptoms

STG (6 sessions \ 2 weeks)

1. Pt will eliminate pain
2. Pt will ↑ strength on B knee extensors
3. Pt will have minimal difficulty as to sit to stand

PT PLAN:

1. PRE x B quadriceps x 3 secs hold x 10 reps x 1 set x od x sitting using ankle weights 2 lbs
 2. Aerobic exercise x LE bike ergo x 30 mins x 3x/week
3. Arome x B knees x 10 reps x 1 set x od
4. Functional Training x Sit to stand as tolerated inside parallel bars
5. Patient education about proper body mechanics

HEP:

1. PRE x B quadriceps x 3 secs hold x 10 reps x 1 set x od x sitting using improvised ankle weights (sandbags 2 lbs)
2. Functional Training x Sit to stand as tolerated c supervision of caregiver

3. Arome x B knee joint motion x 10 reps x 2 sets x od

4. Patient education about proper body mechanics and modify chairs as well

PREPARED BY:
Julia Sacha Marie M. Mendez
Danison P. Pulgar