PHYSICAL THERAPY INITIAL EVALUATION

Patient Name: Margaret (Maggie) Foote Evaluation Date: 11-22-2022

DOB: 2-14-1941
Referring Provider: N/A
Medical Diagnosis: Parkinson’s Disease (G20)
PT Diagnosis: R Hip Pain (M25.551); Low Back Pain (M54.5); Decreased balance
(R26.81); Decreased endurance (Z72.3)
CPT CODE Time (minutes)
Initial Eval (Low Complexity) - 65
97161
Patient Education - 98960 10
SUBJECTIVE: Patient presented to PT with chief complaint of back and bilateral hip pain, that has
been present for the past 5-7 years, but has increased in the past 1-2 years. At the time of appointment,
patient described pain only in R hip, but shared that her pain moves day to day from her back to hips.
When patient walked into treatment area, she described pain as 6/10, but after sitting, pain decreased to
2/10. Patient also has Parkinson’s Disease, which causes symptoms of chin tremor and restless legs.
Patient shares that medication helps reduce these symptoms, but she often forgets to take it as she does
not have a schedule for taking them. Patient reports that PD symptoms have not progressed since
diagnosis in 2017. Additional symptoms include difficulty sleeping, numbness of feet in the morning,
and occasional finger stiffness and pain, which goes away with movement. For pain, patient takes
Tylenol and application of heat and cold. Patient shares that Tylenol doesn’t help pain anymore, but heat
and cold for 15–20-minute increments do. Patient is getting an MRI and biopsy this month for back pain
and loss of foot sensation, respectively. Patient wears orthotics to avoid foot pain.

Patient lives in a one-story home with stairs only to get to basement. Patient reports no difficulty with
stairs but doesn’t like to look down them as she descends. She does not often need access to the
basement as it is used for storage. She lives with her husband, and 3 of her 4 adult children live in the
area. Patient had no falls in the past year, but reported tripping over objects occasionally, and bumping
into husband when walking next to him.
PMH: High blood pressure, Lumbar fusion, Rotator Cuff Tear of R UE, Bilateral Carpal Tunnel
Syndrome.
Medications: Eliquis (Apixaban - anticoagulant medication - prevent blood clots and stroke in atrial
fibrillation patients), Synthroid (Levothyroxine – hypothyroidism), Spironolactone (Diuretic for high
blood pressure), Coreg (Carvedilol – Beta blocker for high blood pressure and heart failure), Potassium,
Pramipexole (Dopamine promotor for Parkinson’s Disease), Sinemet (Levodopa – Treat Parkinson’s
Disease), Vitamin B2, Zioptan (Tafluprost – Glaucoma medication).
Current/Prior level of function: Prior to patient’s PD diagnosis, her and her husband lived on a farm
where she helped with the farm work. She has not had this level of activity since moving into town.
Now, patient attends the exercise class MOVE! For Health weekly but does not attend other exercise
classes. Occasionally, the patient will try to walk around the block but typically has to cut her walk short
due to back and hip pain. Patient does not work and reports no other hobbies.
Patient goals:
1. Decrease low back and bilateral hip pain
2. Be able to walk around the block without stopping for pain
3. Get on a schedule for taking medication daily

Foote, Margaret DOB: 2-14-1941

OBJECTIVE:
Vital Signs: Position/Arm used BP Pulse RR Pulse Ox
Sitting/L UE 128/82 72 12 97
Communication, Cognition, Orientation: AOx4. Patient’s cognition was further tested with application
of the MOCA. All cognitive domains of the test were normal except for below average scoring of memory
and attention. Overall score was 23/30, suggesting mild cognitive dysfunction.
Cranial Nerve Screen: Cranial nerve screen is indicated due to neurological diagnosis of Parkinson’s
Disease. Cranial nerves screened were normal function with no abnormal findings noted or observed.
Reflexes: All DTR testing came back with bilateral UE/LE scores of 2+ except for the R quadriceps
scoring a 3+ with slight hyperreflexia noted.
ROM: Gross AROM screening observed to be WNL bilaterally for both UE and LE with no pain reported.
Strength: Gross strength assessment revealed 4/5 MMT for bilateral UE and LE, except for L hip flexion
scoring 3+/5. During UE testing, the patient displayed excessive trunk extension during resistance and
was cued to maintain proper upright posture. Patient reports no strength limitations to ADL completion
other than struggling to open jars.
Sensation: UE/LE testing was deferred to next treatment session due to patient attire. Sensation testing
of bilateral, distal LEs revealed a stocking pattern of abnormal sensation. Patient unable to differentiate
between sharp and dull, as well as unable to sense the presence of contact to bilateral feet. Lack of
sensation was more severe on the plantar aspect of the great toe, medial foot, and plantar surface,
bilaterally.
Posture: Patient maintains upright posture and body mechanics in both sitting and standing. Patient
observed to have a slight forward head with rounded shoulders. The patient sits and stands in slight trunk
flexion with increased thoracic kyphosis, along with decreased weight shift when completing dynamic
activities and decreased axial rotation ROM.
Balance: Patient maintains both static and dynamic posture in sitting independently without the use of
UE for support. Standing balance was assessed through the completion of the MiniBESTest scoring
anticipatory and reactive balance control, sensory orientation, and dynamic gait tasks. Overall score was
21/28, with below average scoring for both reactive and anticipatory postural control and walking with
dual task. During postural control testing, the patient displays reliance on hip strategy to maintain upright
position with weak or unresponsive ankle strategies and an increase of postural sway in both medial/lateral
and anterior/posterior directions. Posterior postural sway was greatly increased when visual input was
removed. Gait with dual task displayed a severe impairment with the patient stopping completely in order
to count.
Gait/Locomotion: Patient ambulated with a slight Trendelenburg gait pattern, with R trunk lean during
stance phase to compensate, with a slight increase spent in R LE stance. Patient has limited forward pelvic
and trunk rotation during movement. Patient completed the 2-minute walk test and ambulated 383’8”
without resting. During testing, pain increased from 2/10 to 5/10 at the end of the walk, with the patient
reporting a shooting pain down the posterior aspect of the thigh.
Today’s Treatment: Initial examination performed followed by extensive patient education regarding
diagnosis, plan of care and treatment goals. The patient verbalized understanding and gave consent to
treat.
ASSESSMENT:
Precautions: Low fall risk as scored by the MiniBESTest. Patient is on beta blockers and medication
for high blood pressure, with reported tendency about forgetting to take prescribed medication. LBP and
bilateral hip pain that increases with activity. Low aerobic capacity with increased fatigue.

Foote, Margaret DOB: 2-14-1941

Problems list: Hip and back pain, L hip flexion weakness. Decreased balance. Impaired gait. Impaired
memory. Decreased endurance/aerobic capacity. Abnormal posture. Decreased sensation in feet
bilaterally. Decreased ability to walk community distances without pain or support. Unable to stand for
long periods of time while cooking or doing laundry without taking breaks. Unable to grocery shop
without taking breaks and leaning on cart.
Rehabilitation prognosis: Good. Patient is motivated to decrease hip and back pain, and work on gait
and balance. Patient has strong familial support system who are physically capable to help her as
needed. Patient’s home environment is accessible is accessible without straining patient to complete
ADL’s. Parkinson’s symptoms are minimal and not progressed to a severe level. They do not impair her
normal functioning and she completes ADLs with minor compensation strategies.
Short term goals: (2 weeks)
1. Patient will improve MiniBEST score to a 2 in all reactive balance categories to show improved
balance and ability to navigate obstacles in the home and community.
2. Patient will be able to complete a 2-minute walk test without reporting an increase in hip or back
pain, to work toward patient goal of walking with no pain.
3. Patient will create an effective daily schedule to take medication on time to prevent increased
symptoms from not taking medication and improve quality of life.
4. Patient will be able to stand and perform reaching activities for 5 minutes without sitting down to
improve endurance ability to perform functional activities such as cooking without taking breaks.
5. Patient will be independent in comprehensive HEP to continue after session of PT is complete.
PLAN:
The patient will be seen for physical therapy 2x a week for 40-minute sessions, consisting of 2 weeks.
Treatment will consist of therapeutic exercise, activities, and neuromuscular re-education to improve
dynamic balance and reactive control strategies, stability and endurance in standing, and gait training to
assist the patient with proper body mechanics and increase aerobic capacity. The patient will be
instructed in an extensive HEP for self-management of symptoms, including patient education on proper
exercise technique, frequency, and duration. Patients will be educated on the duration of PT as well as
the expected outcomes of rehabilitation. Patient will be reassessed after 2 weeks. Please contact me
regarding any concerns or questions that you may have.
Treatment: Patient was educated about diagnosis and what to expect throughout remaining treatment
sessions. Patient was also educated on bridging exercise to work on at home prior to next appointment.
Obtained patient consent to evaluation treatment at appointment on 11-22-2022.

Sydney Wynne, SPT. Cole Sing, SPT. Date: 11-22-2022

Foote, Margaret DOB: 2-14-1941