INITIAL EVALUATION

Patient’s Name: F.B

Age: 73 y/o
Sex: Male
Address: San Fernando, La Union
Civil Status: ` Married
Handedness: (R)
Occupation: retired nurse
Religion: Roman Catholic
Referring Dr.: Dr. R
Referring Unit: OPD
Rehab Dr.: Dr. P
Date of Referral: August ,2016
Date of Consultation: August ,2016
Date of Eval: Jan 20 , 2016
Diagnosis: (L) hip OA- elective total hip replacement

S:

C/C: “sumsakit yung kanang hita ko ps 6/10 , napapansin ko ding nahihirapan na akong maglakad
at tumayo sa kama ”
C/O: Radiating constant pain extended down from the front of his ® thigh c a PS of 6/10 (using
VAS). Pt. notice that she has difficulty in walking and stand on the bed

HPI: Present condition started 6 mos. PTIE when pt. felt increasing pain c a (PS 6/10) in his ®
hip and noticed he was having difficulty walking and getting out of bed. Pt. asked medical advice to
 Dr. R and he was diagnosed with severe left hip joint degeneration related to osteoarthritis. Dr. R
suggested that pt. undergo an elective total hip replacement. Pt.’s reported that on arrival to the post
op pt. was placed in a semi-Fowler’s position with an abduction pillow between his legs. Pt. states
that he was drowsy and oxygenated through a facemask. Pt. states that she was asleep during the
operation. Pt. was transferred to the surgical ward after a 60 minute stay in OR. P 2hours after pt.’s
return to the ward he was observed to be in pain, reported his pain score as 5/10 and was distressed
and restless. Pt. relieve the pain by taking Oral OxyContin 10mg BD.The following day p the operation
. Pt was referred for PT treatment (unrecalled) stated his pain was “much improved”.

PMHx:
(+) HPN (celecoxib, 400 mg, BID)
(+) heart Dse
(+ Unrecalled
(-) DM

FMHx:
F M
Cancer (+) (-)
DM (-) (-)
Heart Dse (-) (-)

PSHx: Pt. is a non smoker and a non-alcoholic beverage drinker and not abusing any
substance. Pt. lives in a 2-storey building with his wife, daughter and son-in-law. Main door to Living
room: 3 steps; Living room to Bed room: 12 steps; Main door to Kitchen: 7 steps; Comfort room to Bed
room: 6 steps. Pt’s room is situated in the ground foor.

Goal: "Gusto ko mawala na yung sakit at kahit papano makatayo ako sa kama ".

O:

VS: BP= 130/90mmHg

PR= 80 bpm

RR= 18 cpm
 To= 37oC

OI: Manner of arrival: Ambulatory c assistive device

Mental status: Alert/ Coherent/ Cooperative

Body type: Ectomorph

Trophic skin changes: (+) erythema on ® hip

Atrophy: (+) hamstring m & quads m

Postural deviation: (+) (see Postural analysis)

Attachment: (-)

PALPATION:
Thermal assessment: All body parts are normotermic except for a hyperthermic on ®
inguinal area.
Tone assessment: Normotonic on ® hip
Tenderness: (+) gr. II tenderness on ® groin area c dull, aching pain when palpated
Muscle spasm: (+) d/t muscle guarding
Swelling: (+) on ® hip

Tightness: (+) on hip jt.

Edema (grade & type): (-)

ROM:
Findings: Motions of (B) UE/LE, neck and trunk were assessed actively, and are WNL
except for the ff:
Difference
 Motions AROM PROM (N) Endfeels AROM PROM

® hip 0 – 20o 0 – 23o 0 – 30o Empty 10 o 7o

extension

® hip flexion 0-50 o 0-56 o 0-120 o Empty 70 o 64 o

® hip internal 0 – 38o 0 – 40o 0 – 45o Empty 7o 5o

rotation

® hip external 0-30 o 0-33 o 0-45 o Empty 15 o 12 o

rotation

® hip 0 – 30o 0 – 35o 0 – 45o Empty 15 o 10 o

abduction

® hip 0 – 18o 0 – 20o 0 – 30o Empty 12 o 10 o

adduction

Sig: LOM 2o to pain

MMT:
Findings: All major (m) of (B) UE/LE were grossly graded 5/5 except for:
Muscles Grade
® hip extensors 3/5

® hip flexors 3/5

® hip abductors 3+/5

® hip adductors 4/5

® hip internal rotators 4/5

® hip external rotators 3/5

Sig: (m) weakness 2o to inactivity

 ST:
(+) Trendelenburg’s sign
(-) Ober’s Test

Sig: 2o to pain on ® hip

NEUROLOGIC EVALUATION:
Sensory Testing
Devices Used: Pin for pain, brush for light touch and thumb for deep P°
Findings: 100% Intact sensation

Sig: Intact sensory pathway

DTR:

(L) (R)
++ ++

Legend: 0 areflexia

++ + ++
hyporeflexia

++ normoreflexia

++ ++
+++ hyperreflexia

++ ++
++++ clonus
 ++ ++

Findings: Normoreflexive on (B) UE/LE

Sig: Intact reflex arc

ANTHROPOMETRIC MEASUREMENT:

Limb Girth Measurement:

Landmark L R Difference
3” 54cm 52cm 2cm
2” 48cm 46cm 2cm
1” 45cm 42cm 3cm
Patella 42cm 42cm 0

Sig: 2o to muscle atrophy

PA:
Findings:
Anterior View:
® Sh. Is higher than (L) sh.
® lat. curvature
(L) iliac crest is higher than the ® iliac crest
® hip slightly adducted
® knee is lower than (L) knee
® genu valgum
®foot pronation

Posterior View:
 ® Sh. is higher than (L) sh.
® scapular elevation (L) iliac crest is higher than the ® iliac crest

Lateral View:
head forward
® sh. Elevation

GA:
Stance Phase (L) (R)
IC + _
LR + _
MS + _
TS + _

Swing Phase (L) (R)

IS + Decrease
MS + Decrease
TS + Decrease

Sig: Antalgic gait on ® side of the body 2 o to pain

Functional Analysis:
ADL’s FIM LEVELS
Self-care No Helper
Feeding : 5 7- Complete independence
Grooming :6 6- Moderate independence
Dressing :4 5- Minimal independence (subject 100%)
Bathing : 4 4- Modified dependence, Min. Asst. (75%)
Toileting :4 3- Modified dependence, Mod. Asst. (50%)
Bed Mobility 2- Complete dependence, Max. Asst. (25%)
Roll to right: 6 1- Complete dependence, Total Asst. (less
Roll to left :7 than 25%)
Supine to sit: 5
Sit to supine: 6
Transfer
Bed to chair :4
Sit to stand :4
 w/c to toilet : N/A
Ambulation :4

Sitting/Standing Balance Tolerance: N/A

A:
.
PT Impression: Pt. is a 73 y/o female has difficulty in self care, , bed mobility and transfer(d/t
pain on (R) hip 2o hip arthroplasty

Procedural Intervention: Compensatory Intervention

Rehabilitation Potential: Good d/t intermittent s/sx

Prognosis: Pt has a good prognosis that complies with PT Mx base on rehabilitation potential
and family support.

Problem list LTG (24tx session) STG (12 tx session)

1. Pain and tenderness on Pt will demonstrate proper
his R hip with PS 6/10 body mechanics & observe
proper posture to ↓ the
occurrence of pain p 3 wks
2. Limited ROM on ® hip Pt will achieve near (N) ROM
ext.,flex., int. rot, ext. on ® hip extension, internal
rot,abduction, & rotation, abduction, &
adduction. adduction within 5 wks
3. (m) weakness on ® hip Pt will achieve optimum (m)
extensors &flexors, strength on (R) hip
internal& external extensors,flexors, int.
Pt. will report a ↓ pain on
® hip from 6/10-4/10 p 3
days of tx
Pt will increase ROM by 3o
increments on ® hip
extension, internal
rotation, abduction, &
adduction p every tx
session
Pt will increase (m)
strength by 5o increments
on (R) hip extension,
 rotators, rotators, ext internal rotation, &
abductors&adductors rotators,abductors & abduction p every tx
muscles adductors within 5wks session

4. Pt. has max difficulty in Pt. will demonstrate (N) Pt will report a ↓ diff. in
performing functional functional act. w/n 5 wks of performing functional
activities such as tx. activity within 3 wks of tx
walking, climbing stairs, session
and sitting
5. Pt has mod difficulty in Patient will easily perform Patient will easily perform
performing ADLs such ADLs(bathing,eating,doffing ADLs(donning and doffing
as donning and doffing and donning) c no difficulty of pants & socks, urinating
of pants & socks, w/n 4 wks of tx. & defecating) mod  min
urinating & defecating difficulty w/n 2 wks of tx.
6. (+) Postural deviation Pt will achieve (N) posture & Pt will report a decrease
proper body mechanics within postural deviations & m
5 wks. guarding within 3 wks of tx.

P:

PT Mx:
Pt will be treated as an OPD for 24 tx session
1. US x 1.5 W/cm2 x 5’x2x/wk on ® hip to pain and promote healing
2. PRE’sx2x/wk on ® LE c 1lb AWx10repsx1set AP to increase m strength
3. Aquatic ex. x20’ 2x/wk for jt mobilization
4. Gait training inside // bars c obstacles x 5 rounds
5. Mini squat x5SHx10reps
Precaution:
BP