SimucaseTM2019

Physical Therapy Initial Evaluation

Patient Name: Rip

Date of Service: 60 days ago
80 years old
Referred by: Dr. Tim Clark, MD
Therapist: Jan Smith, PT

Diagnosis: Parkinson’s Disease

Fracture of unspecified parts of lumbosacral spine and pelvis, sequela
History of falling
Unsteadiness on feet
Muscle weakness (generalized)
Other abnormalities of gait and mobility

Subjective:
80 y.o. male with 1-year dx of Parkinson's referred for outpatient PT services.
History provided by pt and daughter, Tammy. Multiple falls with injuries: 11 months
ago (3 rib fractures), 10 months ago (head laceration with 3 stitches), 7 months ago
R pelvic fracture with stay at rehab, 2 months of inpatient rehab, home health and
currently outpatient PT/OT. During this time, pt lost his wife to Alzheimer's. Pt
continues with weakness in legs, use of Zinger electric chair 75% of the time and U-
step walker 25%, unsteadiness on feet. Pt reports "clicking and crunching" R hip.
PLOF: SPC use in private home

Pain
Pain Frequency: Constant in low back. Pain Quality: Dull. Pain Radiation: Pain
does not radiate. Pain is worst following exercise class.
Symptoms
Primary Symptoms: Poor Balance, abnormal gait and mobility with fall risk.
Related Symptoms: Anxiety.
General Health Questions
Other Health Problems: Occasional dizziness or vertigo that he feels is
contributing factor to falls. Pre-existing Conditions: arthritis in back. Leg length
discrepancy left leg 1-1.5 inches (wears shoe lift), stent placement heart 5-6 years
ago. Complicating Factors: Age. Gait: Abnormal with feet freezing in thresholds
and tight spaces. Vision Problems: Patient denies any vision problems with glasses
on. Pt also has dentures.
Onset
Date of Onset: 7 months ago. Onset Due To: At home injury. Mechanism of Injury:
Fall with R pelvic fracture.

Referral
Stated Reason for Referral: improve gait, balance to reduce fall risk. Referred by:
PCP
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Bed Mobility ADL

Prior Level of Function: Prior to this injury/episode, patient had little difficulty
with bed mobility.
Ambulation Function
Ambulates for Distance: Over 100 feet, narrow base of support, crosses feet and
allows outside of Ustep. Ambulation Aids: Uses Ustep walker with light beam and
cadence. Pt's feet freeze in thresholds/small spaces. Ambulation Endurance: 5
minutes or less. Ambulation Problems: Unsteady gait, needs Ustep walker, narrow
base of support, bilateral knee flexion, trunk flexion, cervical flexion, festinating gait.
Prior Level of Function: Prior to this injury/episode, patient already had some
difficulty with ambulation using SPC, was seeing PT.

Home Environment
Ambulatory Aids: Ustep walker. Caregivers: Daughters. Patient is living
independently in new living quarters of ILF. Durable Medical Equipment: Rails,
grab bars, elevated toilet seat, shower chair, bed cane. Environmental Barriers:
Carpeting.

Objective:
Vitals: BP120/60, HR 69. Pt wears call light.

Transfers
Sit to Stand: Minimal Assist with lift chair, LOB posteriorly with bracing posterior
legs for assistance. SBA for safety cues. Sit to Stand Technique: Needs hands but
doesn't use in proper position; doesn't transfer center anterior weight over base of
support enough. Sit to Supine: Modified Independent using bed rail. Sit to Supine
Technique: Long sit. Stand to Sit Technique: Use of Ustep, turning >360 degrees,
not pulling Walker fully back, uncontrolled sit, occasionally without hands, but
needs them for safety. Supine to Sit Technique: Long sit. Does not like to lie on R
side due to R pelvic discomfort.
Transfer Sit to Stand: Able, but unsafe

Strength Screening
Results Note

R Upper
Normal 4/5
Extremity

L Upper
Normal 4/5
Extremity
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hip flexion 3-/5

R Lower Abnormal(hip flexion and
abd 3-/5
Extremity abd 3-/5)
adduction/Quads/HS/DF 4-/5

Hip flexion/Quads/HS/DF/adduction
L Lower
Abnormal(hip abd 3/5) 4-/5
Extremity
hip abd 3/5

Tone Examination:
Slight cogwheel rigidity present in right LE greater than left LE.

Pain During Motion:

Extension: Positive- increased LBP with erect standing with gait
Flexion: Positive- increased LBP with sitting in recliner

Painful Motions:
End Range Pain: Extension and Flexion
Sensation
Sensation: Patient has no complaints.
Posture and Alignment
Kyphosis: Yes with forward head. Narrow BOS.
Psych/Soc
Affect: alert, pleasant, cooperative, good historian. Quiet voice.
Observed Pain Behavior: None. Reported 3/10 ache in LB with walking.
Current Status
Potential Red Flags: unsafe mobility with high fall risk.
Current Medications: Finasteride (prostate), Atenolol (beta blocker), Amlodipine
(calcium channel blocker), Atorvastatin (cholesterol), aspirin (blood thinner),
carbidopa/levodopa (Parkinson's), escitalopram(anti-depressant),
Tamsulosin(prostate).

Verbal Pain Rating at Present: 3 - Slight Pain (1 - 3) low back pain

Verbal Pain Rating at Best: 3 - Slight Pain (1 - 3) low back pain
Verbal Pain Rating at Worst: 8 - Severe Pain (7 - 9) low back pain following ex class

Durable Medical Equipment

Wheelchair: Independently uses power "Zinger" w/c used outside of apartment.
(approximately 75% of time per daughter, Tammy). Assistive Mobility Devices: U-
Step Walker with light beam and cadence, used inside the apt. (approximately 25%
of time) up to 100'. Special Equipment: bed rail, elevated toilet seat, rails.
Home Environment
Home Lay Out: OT assessed and reported well set up. Open layout. Necessary
equipment in place.
Medical History
History of Falls: Two or more with injuries. History of Wounds: head laceration
with fall. Prior Concerns / Co-morbidities: Abnormal gait due to Parkinson's with
falls; spouse passing away needing low dose antidepressants.
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Shoulder Active ROM

Shoulder Flexion Active ROM

R Upper Extremity 150 degrees

L Upper Extremity 150 degrees

Shoulder Flexion PROM

R Upper Extremity 150 degrees

L Upper Extremity 150 degrees

Shoulder Abduction PROM

R Upper Extremity 150 degrees

L Upper Extremity 150 degrees

Hip Joint
Hip Passive ROM Left Right

Hip Abduction PROM 20 degrees 20 degrees

Hip Adduction PROM 5 degrees 0 degrees

Hip Extension PROM 0 degrees 0 degrees

Hip External Rotation PROM, hip flexed 90 45 degrees 20 degrees

Hip Flexion PROM 120 degrees 90 degrees

Hip Internal Rotation PROM, hip flexed 90 0 degrees 0 degrees

Functional Assessments

Tinetti Balance Test- Balance Section

Test Item Results

1.Sitting Balance 1
2.Rises from chair 1
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3.Attempts to Rise 1
4.Immediate standing Balance (first 5
1
seconds)
5.Standing Balance 1
6. Nudge 2
7. Eyes Closed 0
8a. Turning 360 degrees 0
8b. Turning 360 degrees 0
9. Sitting down 1
Total Balance Score 8

Tinetti Balance Test- Gait Section

Test Item Results

1. Indication of gait 0
2a. Step length and height 1
2b. Step length and height 1
3a. Foot clearance 0
3b. Foot clearance 0
4. Step symmetry 1
5. Step continuity 0
6. Path 1
7. Trunk 1
8. Walking Time 1
Total Gait Score 6
Total Balance and Gait Score 14- high risk of falls

6MWT: 320 meters

Gait speed: 0.8 m/sec

Evaluation Complexity

Health History

Personal factors noted in history affecting plan of care include: Age, recent loss
of spouse. Comorbidities affecting the plan of care: R pelvic fracture with
shortened hip musculature, Parkinson's.

Body Systems and Functions

Musculoskeletal Regions: Bilateral Legs weak R > L, LBP chronic due to OA/DJD.
Cardiovascular System: Hx of stent; on cardiac meds. Neuromuscular System:
Brain and Central Nervous System involvement with Parkinson's Disease. Activity
Limitations and Participation Restrictions: General tasks and demands, recent
loss of wife, new community.
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Functional Assessment Tool Scores

Pain Rating Notes
Functional pain scale 3 - Functionally disabling. LBP

Assessment

Complexity and Safety

The treatment plan is too complex to be performed effectively by the patient
or by a caregiver for the following reasons: skilled manual therapy that cannot be
performed safely by an untrained caregiver. exercise instruction and supervision
requiring the knowledge, skills, and expertise of a therapist. instruction in ADLs that
require the knowledge, skills and expertise of a therapist. The treatment plan
requires the skills and expertise of a therapist because of the following safety
reasons: high risk for falls.

Necessity
Exercise Instruction and Monitoring: Safety, pain. Accepted Standard of
Practice: Amount, duration, frequency and type of treatment is reasonable under
the accepted standards of practice. Patient Dependence: Services cannot yet be
performed independently by the patient or other caretakers.
General Diagnosis
Description: Parkinson's disease with gait abnormality and hx of falls with injuries.
Assessment of Impairments
Barriers To Rehab: Possible emotional factors, pain. Rehabilitation Potential:
Excellent for goals set.

Plan
Plan of Care
Frequency: 2x weekly. Duration: up to 90 days until goals met. Home Exercises:
Pt to receive patient handout. Other Instructions: safe transfers. Supervised
Exercises: balance training. Plan of Care Discussion: Discussed plan of care, goals
and prognosis with patient. Patient understands and agrees to plan of care.
Patient/Family/Caregiver Education: Patient expressed understanding of
evaluation and agreement with goals and treatment plan. Described results of
Evaluation. Patient requires further education on strategies and risk.
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Recommendations

It is recommended that patient: continue therapies as recommended on most

recent evaluation. Following Discharge: Continue with home exercises. Patient to
phone clinic prn. Telephone Clinic: If there is any problem with home exercises or
home program. If there is any question about the treatment plan. If there is any
question regarding our discussion of the nature of the problem.

Procedures

CPT
Minutes Note
Code

New- PT 30 Pt evaluated, POC created, discussed and agreed upon 97161

Evaluation, Low POC
Complexity

Therapeutic 9 Exercises for decreased range of motion creating gait 97110

Exercise abnormality, balance and/or coordination deficits,
abnormal posture, muscle imbalance, sit/stand ex x 5
instructed, safety training with transfers; handout
provided

Manual Therapy 0 Includes soft tissue mobilization, joint mobilization, 97140

manual traction, and/or muscle energy to address
restricted joint motion, shortened muscles and
connective tissue and/or painful spasms that impaired
functional performance.

Therapeutic 36 Includes dynamic activities that are designed to 97530

Activity improve functional performance, movement quality
and safety when transferring, reaching, bending,
squatting, shifting weight; transfer and safety training;
proper use of Ustep walker in backing to chair

Neuromuscular 0 Activities that facilitate re-education of movement, 97112

Re-education balance, posture, coordination, and
proprioception/kinesthetic sense. Stabilization
exercises.

Gait Training 0 instruction in the use of an assistive device; sequencing, 97116

addressing quality/asymmetry, and negotiating
environment with improved safety. Stair training.
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Wheelchair 0 97542
Management

Short term goal: Client will demonstrate independence with home exercise
program and in use of recumbent equipment in gym within 4 weeks.

Short term goal: Client will consistently participate in community exercise classes
3x/week to maintain progression in strength and function within 4 weeks.

Short term goal: Client will ambulate over 300 feet with U-step walker to/from
meals and activities with modified independence, and 0 cues for safety precautions
to reduce risk of falls within 4 weeks.

Short term goal: Client will demonstrate sit to stand transfers with modified
independence and 0 cues for safety precautions to improve functional independence
within 4 weeks.

Long term goal: Client will demonstrate improved functional mobility and reduced
risk of falls as indicated by a 5-point gain on the Tinetti assessment within 8 weeks.

Long term goal: Client will demonstrate improved passive range of motion in right
hip external rotation by 15 degrees in order to reduce pain and improve gait quality
within 8 weeks.

Long term goal: Client will demonstrate improved right hip flexor and abductor
strength by one MMT grade in order to improve gait deficits and reduce risks of falls
within 8 weeks.

Long term goal: Client will demonstrate improved left hip abductor strength by one
MMT grade in order to improve gait deficits within 8 weeks.

Long term goal: Client will demonstrate improved functional mobility by using U-
step walker independently used in community to and from meals/activities
approximately 75% of time within 8 weeks.

Long term goal: Client will demonstrate improved functional mobility by

independently using power “Zinger” wheelchair outside of community only and
approximately 25% of the time within 8 weeks.