Student PT Name: Matthew Bersano

Physical Therapy Evaluation / Plan of Care Form

Patient Information and Demographics:

Name: Mildred (prefers: Mil) Age: 55 Gender identification: Female

Date of Service: 10/12/22

Administrative Codes:
PT Diagnosis (ICD-10): R27.8 - Lack of Coordination; R26.81 - Unsteadiness on Feet

Medical Diagnosis (ICD-10): G20 - Parkinson’s Disease

Current Procedure Terminology Units Duration

(CPT) Billing Codes
97161 - Low Complexity Eval 1 50
97530 - Therapeutic Activity 1 12

SUBJECTIVE:

CC / Reason for Referral: Early Parkinson’s Management

Onset and History of symptoms:

The patient came to PT after a diagnosis of probable early Parkinson’s disease. She reports feeling more
fatigued with physical activity, such as running; experiences a periodic tremor in her right hand; and fell
about 2 weeks ago. The tremor began about a year ago. She fell when walking from wood to carpet, due
to her foot catching the carpet, and bruised her right knee. She also reports having difficulty with going
to the bathroom. She also complains about feeling unsteady when swinging her golf club.

Previous Medical and Surgical History:

Appendectomy - 7yrs ago

Current Medications:

Medication Reason this patient is taking Dose and Frequency

Artane (Trihexyphenidyl) Stress Incontinence - May not help 2mg TID
Multivitamin General health OD
Calcium with Vitamin D Bone Health/Osteoporosis 600mg OD
Soy Isoflavones Cholesterol, fatigue 80mg OD
Black Cohosh General Health 40mg OD
This is a menopause supplement

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 Student PT Name: Matthew Bersano

Level of Activities Prior to Current Onset:

The patient reports exercising 5 days a week. She golfs one day during the weekend and runs 4 days
during the week. She runs longer distances, up to 10-12 miles. She also enjoys spending time with her
family. During the winter she Cross Country Skis.

Home /Work/ Other Relevant Environment(s):

The patient lives in a 2 story home, with 3 steps to get into her home and 13 steps to get to her second
floor.
She works as a librarian at the University of Kansas, which is on the main floor.

Psycho-social / Family Support / Family Responsibilities:

Her husband is 63 years old and retired. Her children are both adults and close to home, both attending
the University of Kansas for post-graduate degrees. They are all willing and able to help at home.

Relevant Dietary / Elimination Issues:

The patient asked about taking several OTC supplements, such as Selenium, B-vitamins, coenzyme
Q-10, and vitamin E. I told her that, although they shouldn’t harm her, since they are approved by the
FDA, I couldn’t guarantee they would help. It was out of my field of expertise to make any affirming
statements about the supplements. These are good questions to refer back to a doctor or nutritionist! Good job "staying in
your lane" ;)

History of falls:
The patient reports having a fall two weeks ago, but no other falls.

Client Goals:
The patient wants to get back to work and return to her normal activity, without fear of falling.

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 Student PT Name: Matthew Bersano

OBJECTIVE (add other items as indicated):

Vital Signs:
Position / Arm used BP HR Pulse O2 Comments
Sitting 118/78 59 97%
Standing 103/71 Not Taken Not Taken The patient felt
lightheaded upon
standing, but the
episode was
resolved after a
moment

Communication, Cognition, Orientation:

A&O x 4

Reflexes:
Reflex Right Left Remarks
Patellar 2+ 2+
Brachio-radialis 2+ 2+
Biceps 2+ 2+
Triceps 2+ 2+

Cranial nerves and related systems

Is a cranial nerve screen indicated for this patient: Yes, Parkinson's Disease is able to affect the
cranial nerves, such for smell and the Pharynx.

All Cranial Nerves are intact

ROM, Strength, Tone, Patterned Movement:

All ROM and Strength tests are WNL, but the patient complained of tightness in her R. shoulder.

Coordination (see O’Sullivan text):

Test Right Left Remarks
Finger to Nose Poor* Poor *Can’t touch PT’s finger and
slow
Heel to Shin Good Good

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 Student PT Name: Matthew Bersano

Sensation:
Right Upper Extremity Left Upper Extremity
Light Touch Intact Intact
Vibration Intact Intact
Hot/cold discrimination Intact Intact
Right Lower Extremity Left Lower Extremity
Light Touch Intact Intact
Vibration Intact Intact
Hot/cold discrimination Intact Intact

Bed Mobility and Transfers

The patient was able to perform all transfers independently, with FIM grade 7.

Posture:
The patient showed no abnormal postural deviations.

Balance:
The patient has normal static balance and was able to stay upright during the Pull Test.

Gait/Locomotion:
Gait was unremarkable, as well as ascending and descending stairs.

Standardized Tests:

Test Score Interpretation / Rationale

Berg Balance 56/56 The patient is independent
Test

ASSESSMENT:
The patient appears to be independent and healthy, presenting with early symptoms of Parkinson’s
Disease. These include decreased dynamic balance when participating in activities and a periodic
tremor, as well as some incoordination with her right UE. She appears highly motivated to prevent the
progression of her symptoms.

Precautions:
- Fall Risk

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 Student PT Name: Matthew Bersano

Problem List
- Diminished Dynamic Balance (with golfing)
- Impaired Coordination

Rehabilitation Prognosis: Good

GOALS:
Short Term Goals (2 weeks)
1) The patient will affirm understanding of the importance of performing her HEPs for the
prevention of the progression of her Parkinson’s symptoms.
2) The patient will be able to correctly perform her HEP without verbal or tactile cueing, to be able
to safely perform her exercises at home.

Long Term Goals (4 weeks)

1) The patient will affirm understanding of the importance of coming back to PT in 6 months to a
year, for a check up on her HEP and Parkinson’s symptoms.

PLAN: Very reasonable plan, well thought out

The patient will come to PT in a week to assess how she is doing and how her HEP is going. If
alterations or corrections are made to her HEP, another visit in a week will be requested, otherwise the
patient will come for a check up in four weeks. Then, if there are no new symptoms or concerns, the
patient will come for a check up in 6 months to a year. The patient was encouraged to continue her
normal physical activity of running, golfing, cross country skiing, and anything else she feels safe doing.

TODAY’S INTERVENTIONS / DOCUMENTATION OF CONSENT:

Today’s Interventions included educating the patient on what PT can and can’t do for Parkinson’s,
demonstrating and running through her HEP, and explaining the importance of her involvement in the
prevention of the disease.

I received verbal consent from the patient today for the evaluation and interventions, the patient
confirmed she understands the importance of performing her HEP and staying active, for the prevention
of the progression of Parkinson’s Disease symptoms.

I certify / recertify that the above therapy services are necessary, and I agree with the plan of care above.

__________________________________ __________ Matthew Bersano 10/13/22

Physician Name/Signature Date Therapist Name/Signature Date

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