Initial Evaluation
Submitted to:
Ms. Teresa Rose Combalicer, PTRP
Submitted by:
Bisquera, John Glenn
Cruz, Wenzy Razzie
Flores, Paul John
Reyes, Dante Jr.
Pts name
: J.R.
Age
: 27 y/o
Sex
:M
Address
: West Avenue, Manila City
Civil Status
: Single
Handedness
: (R)
Occupation
: Student
Referring unit
: Orthopedic Department
Referring M.D
: Dr. G
Date of consultation : Aug. 23, 2016
Date of admission : N/A
Date of referral
: Aug. 23, 2016
Date of IE
: Aug. 23, 2016
Dx
: Grade 3 ankle sprain on (R) foot
S:
C/C: sobrang sakit ng ankle ko tuwing maglalakad o igagalaw ko p/s of 9/10
PT Translate: Pt. stated, Pt. c/o severe pain c a p/s of 9/10 on his R ankle.
HPIx:
Present condition was acquired 2 days PTIE when pt. had a bad fall during their
practice game. The pt. attempted a rebound when upon landing his R foot twisted &
observed c fall. p he opted to sit on the bench because pain is already felt. Swelling
started and throbbing pain is felt throughout the noc. Pain is exacerbated by movement
and relieved by elevation and steady position. In the morning, he went to the hospital for
orthopedic consultation and have x-ray. (see Ancillary procedure).
ANCILLARY
PROCEDURE
FINDINGS
X-ray
(oblique view)
08-23-16
LMC
PMHx:
The pt. self medicated and took paracetamol 500mg 1x for the pain and
mefenamic acid 500mg for the swelling. (-) Htn, (-) Asthma and (-) Heart dse.
FMHx:
Htn
DM
Heart dse.
FATHER
(+)
(-)
(-)
MOTHER
(-)
(-)
(-)
PSHx:
The pt. is an athlete, living in an active lifestyle and has been playing basketball
competitively for 6 yrs. Pt. has no hx of substance abuse, a non-smoker and a social
drinker. Pt. is a student and lives in a 2 storey house (stair steps: 15). States that he
sleeps c his foot elevated on a pillow while his back is lying flat on a firm mattress. He
lives c his parents.
FHx:
Pt. is amb. c the help of bilat. crutches and is able to perform ADLs and personal
grooming c mod. to max. difficulty.
Goal:
Gusto ko nang makalakad ng walang saklay at makabalik sa paglalaro ng
basketball.
O:
VS:
BP: 90/70 mmHg
PR: 70 bpm
RR: 16 cpm
Temp: 37.2 C
OI:
Manner of arrival: Dep. amb c AD bilat. crutches
Mental status: Alert/ Coherent/ Cooperative
Physique: Mesomorph
Findings: All joints of B UE/LE are grossly assessed both in AROM and PROM cc
N end feels, except
Motion
( R) Dorsi-flexion
( R) Plantar flexion
( R) Inversion
( R) Eversion
AROM
N/A
N/A
N/A
N/A
PROM
N/A
N/A
N/A
N/A
END FEEL
EMPTY
EMPTY
EMPTY
EMPTY
(d/t pain upon
movement)
Findings: All muscle of B UE & LE are grossly assessed ccgrade 5/5 except,
Motion
Dorsiflex.
Plantar flex.
Inversion
Eversion
Wrist ext.
Elbow ext.
Shoulder ext.
L
5/5
5/5
5/5
5/5
5/5
5/5
5/5
R
N/ A
N/ A
N/ A
N/ A
5/5
5/5
5/5
Legend:
0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus
IC
(+)
(+)
LR
(+)
(-)
MS
(+)
(-)
TS
(+)
(-)
(bilat. crutches) d/t pain upon wt. bearing in the R ankle. Pt. has poor stairs negotiation
d/t poor techniques in amb. c ADs (bilat. crutches)
PROBLEM LIST
1. Pain on R ankle c a p/s of
9/10
2. Swelling on R ankle
w/n 6 wks.
To eliminate pain on R ankle
3. Gr.3 tenderness on R
w/n 6 wks.
To eliminate tenderness on R
3 wks.
To tenderness on R ankle
ankle
4. Unable to perform ADL
AD (bilat. crutches)
5. Unable to perform
wks.
To be able to amb.
wks
To wt bearing on R ankle
w/n 3 wks.
crutches)
P:
PT Mx:
1.
2.
3.
4.