Initial PT Notes

(September 07, 2022)

SUBJECTIVE
General Information:
Pt’s name: Patrocinia Gaviola.
Age: 85 years old
Sex: Female
Civil status: Widowed
Rehab Doctor: Dr. Frances Carlos
Date of IE: September 07, 2022
Diagnosis: OA of the (R) Knee; Deconditioning Syndrome

HPI:
Present condition started ~ 1 year ago, when patient felt dull, deep pain graded 3/10 (VAS) inside her
(R) knee while standing up & ambulating, further aggravated (pain graded 4/10 via VAS) when going
down the stairs and doing prolonged activities. The patient was initially admitted to the Metropolitan
Medical Center due to her Community-Acquired Pneumonia (CAP) & Acute Respiratory Failure
(ARF) condition. However, upon MD consultation, the patient also stated & complained about the
reproduction of dull, aching pain (grade 4/10 via VAS) that she felt in her (R) knee; thereupon further
evaluation & examination, the MD diagnosed the patient with (R) knee osteoarthritis & was referred
to PT evaluation & management. At present, the patient presents with dull, deep aching pain graded
7/10 (VAS) on the medial side of her (R) knee worse when standing and amb.

Past Medical History

(+) Pulmonary disease (CAP, ARF)
(+) Hypertension, controlled since (does not remember) (See Medications taken)
(-) RA
(-) Dyslipidemia
(-) Stroke
(-) Cardiac problem
(-) PVD
(-) Osteoporosis
(-) Fracture
(-) Cancer

Family Medical History

Condition Maternal Paternal

Osteoarthritis (-) (+)

Rheumatoid Arthritis (+) (-)

HTN (-) (-)

DM (-) (+)

Cardiac disease (+) (-)

Pulmonary disease (+) (-)

Obesity (+) (-)

Hernandez, J.D.
Personal Social History
Patient is a non-smoker & non-alcoholic beverage drinker who typically spends her time at home
playing with her grandchildren, doing household chores such as cooking & cleaning, & doing light
laundry. The patient diet consisted of healthy foods and had always had a good appetite for eating.

Environmental Assessment
Patient lives in a 2 storey house that is well-lit, and c tiled flooring, bedroom located @ 2nd floor
● Stairs = ~ 8 steps; height: 5 in c railings
● Bed height = ~10 in above the ground
● Chair height = 15 in c armrest and backrest
● Bedroom → CR = ~ 10 steps

Home Situation
The patient lives with her children and grandchildren, all of whom can provide care and assistance.
All rehabilitation expenses will be shouldered by the patient’s family.

Medications Taken:
Medication Dosage Frequency Indication

Losartan 15 mg; oral Twice daily HTN maintenance

Amlodipine 5 mg; oral Once daily Lowers the BP by relaxing the blood vessels

Chief complaint
The patient complains of dull, deep aching pain graded 7/10 (VAS) in the medial side of her (R) knee
worse when standing up & ambulating & a dull, aching pain graded 5/10 (VAS) on her (R) anterior
shoulder when moving into shoulder flexion, abduction & horizontal adduction.

Patient’s Goal:
Relief of symptoms such as pain to be able to play & bond with her children and grandchildren again
s difficulty

OBJECTIVE
Vital Signs
VS Before After

Blood Pressure (mmHg) 120/80 mmHg 120/85 mmHg

Heart rate (bpm) 78 bpm 86 bpm

Respiratory rate (cpm) 13 cpm 15 cpm

Axillary Temperature (oC) 36.3 oC 36.7 oC

O2 Sat (%) 95% 97%

Findings: Patients VS are all WNL
Significance: Patient was able to proceed and continue with the rehabilitation session but since she
has an existing pulmonary condition and as per doctor request and orders, VS should always be
closely monitored with utmost precautions to ensure pt’s safety especially when performing exercises

Ocular Inspection
Asleep but was able woke up when called
Coherent and was able to follow command

Hernandez, J.D.
Ectomorph
(+) Attachments
● IV line on the dorsal aspect of the (L) hand
● Nasal cannula
● NGT
(+) Trophic skin changes on all exposed body parts
● Small brown age spots
(+) Senile tremours of (B) UE
(-) Wounds on all exposed body parts
(-) Swelling on (B) UE & LE
(-) Atrophy on (B) UE & LE
(-) Pressure sores on (B) UE & LE & back

Palpation
Normothermic on all exposed body parts
(+) Crepitus on (R) knee towards flexion & extension
(+) Muscle guarding on (R) shoulder & knee joint
(+) Grade II tenderness on (R) shoulder and knee joint
(-) Dislocation on (B) UE & LE
(-) Contractures on (B) UE & LE
(-) Edema on (B) UE & LE
(-) Inflammation on (B) UE & LE
(-) Subluxation on (B) UE & LE
(-) Muscle spasm on (B) UE & LE
(-) Nodules on (B) UE & LE
(-) Deformities on (B) UE & LE

ROM Measurement
Motion AROM PROM Normal Difference End-feel

R knee flex 0o-83o 0o-85o 0o-135o 52,50 Hard

R knee ext 135o-21o 135o-13o 135o-0o 21, 13 Hard

L knee flex 0o-115o 0o-120o 0o-135o 20, 15 Firm

Findings: Patient has limited knee AROM and PROM motion in (R) knee flex and ext; complains of
grade 5/10 (VAS) pain and crepitations were felt on the (R) knee throughout the motion
Significance: Patient may have moderate difficulty in doing ADLs such as STS, standing, amb, &
stair nego

FMT
Grading
Patient’s response
R L

Cone Reaching

Patient was assessed in a short sitting position; was able

to perform the activity in (B) UE independently for 2 WF F
rounds each hand. However, on the (R) UE the patient (Weak Functional) (Functional)
has an inc performance time & complains of aching pain
graded 5/10 (VAS) in the (R) shoulder joint, especially
when moving her in shoulder flexion, abduction &

Hernandez, J.D.
 horizontal adduction.

Ball Catching and Throwing

Patient was assessed in a short sitting position; was able F

to perform the activity independently. The patient was (Functional)
able to pass and catch the ball 9/10 correctly and actively.

Heel Slides

Patient was assessed in a supine position; was able to

perform the activity in (B) LE independently. However, WF F
the patient complains of reproduction of pain in her (R) (Weak Functional) (Functional)
medial knee joint upon the performance of the task in
which she slowly took her time before doing it again.

Ankle Pumps

Patient was assessed in a supine position; was able to

perform the activity on her (B) LE independently & s F F
difficulty. The patient was able to perform the activity for (Functional) (Functional)
10 trials each LE.
Findings: The patient was graded WF upon performing cone reaching on her (R) UE and heel slide on
her (R) LE as manifested by moderate impairment & increased performance time further defined by
reproduction of pain which may be brought by her existing condition.
Significance: The patient may have moderate difficulty in performing ADLs that involved her (R) UE
& LE such as overhead reaching, STS and amb

Postural Assessment
Taken c the patient in short sitting position while leg dangling.
Anterior Lateral Posterior

(B) GH joint slightly internally Forward head Protracted (B) scapula

rotated Slight increase of thoracic
kyphosis
Slight decrease of lumbar
lordosis
Findings: Patient presents c stooped posture d/t ageing
Significance: Patient may have difficulty in performing ADLs such as prolonged standing, amb &
stair negotiation

Balance Assessment
Position Balance Grade

Static 3: Good
Sitting
Dynamic 3: Good
Findings: The patient has good static balance as she was able to maintain her balance without
handhold support but presents with limited postural sway; has also a good dynamic balance as she was
able to accept moderate challenge since she was able to reach the cone in different directions
Significance: This may be a factor to also assess the patient in a standing position to get in-depth
details or assessment regarding her functional balance when it comes to standing and doing ADLs
such as bed mobility and STS

Hernandez, J.D.
ADL Assessment
● Supine to Side-lying: Patient was able to perform transfer from supine → side-lying but with
moderate difficulty and requires moderate assistance & close guarding in performing the task
● Supine to Sitting: Patient was able to perform transfer from supine → sitting but with
moderate difficulty and requires moderate assistance & close guarding in performing the task

ASSESSMENT
PT Diagnosis
● MD diagnosis of (R) Knee Osteoarthritis (OA) further defined by difficulty in ADLs such as
standing, ambulation & stair descent due to the reproduction of dull, deep aching pain on her
(R) medial knee joint and (R) UE and LE muscle weakness.

PT Prognosis
● Patient has a fair prognosis to be able to ambulate again independently due to her age and as
well as her existing pulmonary condition (CAP, ARF). However, the pain and muscle
weakness can still be addressed by PT interventions and management, adequate rest, and
taking prescribed medications on time.

Good Prognosis Bad Prognosis

Impairments such as pain & weakness can still (+) HTN

be addressed with continuous PT (+) CAP, ARF Pulmonary condition
Patients condition is MSK in origin with the Old age
absence of any neurological problem
Unilaterally and one knee joint is affected

Rehabilitation Potential
Patient has a good rehabilitation potential as she is cooperative, well-motivated, and willing to
participate in the rehab. She is also willing to comply with the instructions of the PT. Her family is
very supportive and is willing to shoulder all the financial load and make home modifications in order
to cater to her specific needs. Her children and grandchildren are also willing to assist her with the
home exercise program. Her family is also financially capable so there would be no problem when it
comes to finances.

Problem list
● LOM on the ff motion
○ (R) knee flex
○ (R) knee ext
○ (L) knee flex
● Muscle weakness
○ Heel slides = WF
○ Cone reaching = WF
● Pain on her (R) knee joint
● Postural deviation
● Moderate difficulty in transfers from supine → side-lying
● Moderate difficulty in transfers from supine → sitting

Long Term Goals

● Patient will be able to walk inside her home with minimal assistance for at least 5 mins with
the use of an assistive device (quad cane) and in normal pace s presence of pain & difficulty
after12 PT session

Hernandez, J.D.
Short Term Goals
● Patient will be able to manifest an increase ROM towards the ff motions after 6 PT sessions:
○ R) knee flex (AROM = 0o-83o PROM = 0o-85o → 0o-120o)
○ R) knee extension (AROM = 135o-21o PROM = 135o-13o → 135o-7o)
○ (L) knee flex ((AROM = 0o-115o PROM = 0o-120o → 0o-130o)
● Patient will be able to demonstrate improvement in muscle strength through the use of FMT
after 6 PT sessions
○ Cone reaching (WF → F)
○ Heel slides (WF → F)
● Patient will have a decreased pain on the (R) medial knee joint from grade 7/10 → 3/10 after
6 PT session
● Patient will be able to perform ADLs activities such as transfer from supine → side-lying,
supine → sitting c minimal assistance and minimal difficulty for 6 PT sessions
● Patient will be able to perform sit to stand independently c minimal assistance and minimal
difficulty for 6 PT sessions
● Patient will be able to perform prolonged standing independently c minimal assistance and
minimal difficulty for 6 PT sessions

PLAN

MD Suggested Plan
Pt will be seen and treated with the following PT Mx:
● HMP c TENS on the (R) medial knee joint x 10 mins
● Continuous US on the (R) knee joint x 1.5 MHz x 2.0 W/cm2 x 5 mins
● AAROMES of (B) UE and LE x 10 reps
○ Shoulder flex, abd, and horizontal adduction
○ Elbow flexion/extension
○ FA pronation/supination
○ Wrist flexion/extension
● GPS of (B) HC x 30 sec hold x 3 reps
● Short sitting balance tolerance c leg dangling x 5 mins
● MBRE c cone reaching of (B) UE x 2 rounds each
● Bed mobility within patient’s tolerance
○ Supine → side-lying
○ Supine → short sitting
● DDBE

PT Suggested/Additional Plan:
● Gentle Passive Stretching of (B) Quadricep muscles x 30 sec hold x 3 reps
● Gentle Passive Stretching of (B) Hamstring muscles x 30 sec hold x 3 reps
● Muscle setting exercise of (B) Quadriceps x 6 sec hold x 6 reps
● Muscle setting exercise of (B) Hamstrings x 6 sec hold x 6 reps
● Pre-ambulation exercise: sitting and standing weight shifting x 6 reps x 2 sets
● Gait training with use of quad cane x until patient tolerance
● UE ergometer x 10 mins
● LE ergometer x 10 mins
● Functional exercise: STS x 10 reps

HEP
● HMP on (R) medial knee joint x 10 mins
● AAROMES of (B) UE and LE x 10 reps
○ Shoulder flex, abd, and horizontal adduction
○ Elbow flexion/extension
○ FA pronation/supination
○ Wrist flexion/extension

Hernandez, J.D.
 ● GPS of (B) HC x 30 sec hold x 3 reps
● Short sitting balance tolerance c leg dangling x 5 mins
● Marching in place c arm in circling motion while sitting x 10 mins
● ISOMEs of (B) knee flex & ext x 10 reps
● DDBE

Patient Education
● Educate the pt. about the dse. Progression
○ Brief the pt. about the course & progression of the dse., how to protect the joint while
remaining active, how to manage presents s/sx, & how PT rehab can benefit her
condition
○ Inform the pt. about relevant risk factors associated c her condition
● Educate pt. on how PT services can help improve her condition
○ PT will help the pt. address the pain, LOM, & weakness of the muscles by providing
therapeutic exercises & modalities
○ PT will provide progressions to the treatments given, in order to help the pt.return to
her N functional capacity
● Management of condition
○ Avoid inactivity as much as possible as it is a common problem for people with
arthritis and may lead to serious deconditioning, depression, lower pain thresholds,
diminished bone and soft tissue health, and increased risk for other serious health
conditions.
○ Pt. should be taught proper positioning when resting & should be encouraged to
perform daily, active ROM as tolerated to maintain motion; Take adequate rest in
between exercises or work related activities
○ Avoid performing movements that may aggravate symptoms
○ Provide alternative ways of performing ADLs that the pt. currently has difficulty on,
in order to avoid exacerbating the condition.
○ Take prescribed medications on time
○ Follow the HEP given; considering the proper parameters, execution of exercises, &
done c supervision
● Signs & pain patterns that the pt. may experience during exercises
○ Always be aware of breathing during exercises to avoid Valsalva Maneuver
○ Remind the pt that stretch sensation will be felt during some of the exercises, such as
stretching, in order to better improve her condition
○ Remind the pt to inform the PT if pain is elicited, unbearable, or untolerated
● Inform pt. & family members of their roles in the healing process of the condition
○ Family Members should be aware of the pt’s condition and be sensitive enough to
adjust when needed to the pt. Needs.
○ Educate the pt. & caregiver about the benefits of adhering to the HEP in order to
hasten recovery
○ Pt. should always be assisted by family members/caregiver when doing the HEPs
○ Do not forget to perform warm-up a doing the HEP & cool down p doing the HEP
○ Remind family members to provide emotional & motivational support to the pt.
● Modify pt’s surroundings
○ Explain how beneficial home & environmental modifications can be to prevent
worsening conditions for the pt.
■ Raise the bed/chair to reduce the effort needed in standing up
■ Placement of railings on the stairs/kitchen/bathrooms
○ Pt. may be advised to switch rooms from the 2nd to the 1st floor to avoid facing stair
negotiations until proper PT training is completed
● Consequences for not following the Pt. education
○ Not following the PT interventions, HEPs and Pt. education may worsen the present
condition and increase risk for future complications

Hernandez, J.D.