DOCUMENTATION CODE: F-MS-RMED008
REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014
Republic of the Philippines
Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER
Department of Rehabilitation Medicine
Capitol Compound Cagayan de Oro City
OUTPATIENT PHYSICAL THERAPY EVALUATION
INITIAL EVALUATION
NAME:
AGE:
Blasco, Demitrio
ADDRESS:
30
HANDEDNESS:
R
Bugo, CdOC
OCCUPATION:
INFORMANT:
SEX: M
machine operator
patient
REFERRING MD: Dr.
Bautista
SIGNATURE:
RE-EVALUATION
MARITAL STATUS:
Single
RELIGION: R.C
DATE OF IE/RE:
(MM/DD/YY)
BIRTHDATE:
(MM/DD/YY)
11/14/1985
HEALTH RECORD No.
972295
CONTACT NUMBER:
09215777205
11/13/2015
TREATMENT SCHEDULE: (MON-TUE-WED-THU-FRI)
M-W-F
REFERRAL DIAGNOSIS: Flexion contracture L hand
/S/
Pt. stated "lisod ipiko akong wala nga mga tudlo"
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Pt current condition started last 08/12/15; pt was on duty @ Galvasteel
when he accidentally inserted his L hand while inserting yero on durarib
machine. His coworkers helped him et was rushed to COMC at around 10
am; at 1:00 pm he had undergone operation c Dr. Kho et was admitted 3
days under general anesthesia.
On 09/2/15, he had undergone open wound operation by Dr. Kho d/t
darkening of the wound site; pt had his check-up on Oct. 10 et was seen c
flexed fingers c inability to extend; he was then referred to Dr. Antolin et on
Oct. 18 he had undergone G plus operation to release the flexor tendons of
the L hand. After the operation, pt had his weekly check-up et was referred
to rehab.
X-ray
@ NMMC (08/12/15, 10/18/15, 11/12/15)
ANCILLARY PROCEDURE (with
dates):
MEDICATION:
none
PAST MEDICAL HISTORY:
Hospitalization 2 dengue (2005)
FAMILY HISTORY:
(-) heredo-familial disease
(+) occasional drinker
PERSONAL & SOCIAL HISTORY:
plays basketball ; lives c his sister
PRIOR LEVEL OF FUNCTION:
(+) ambulatory
indep. in all ADLs; currently stopped working et stays only at home
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N/AMATERNAL HISTORY:
(Prenatal-Perinatal-Postnatal)
N/A
MILESTONE:
GOAL:
gusto na koPATIENT'S
makabalik
og trabaho as stated by the pt.
Republic of the Philippines
Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER
DOCUMENTATION CODE: F-MSRMED-008
REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014
Department of Rehabilitation Medicine
Capitol Compound Cagayan de Oro City
OUTPATIENT PHYSICAL THERAPY EVALUATION
/O/
VITAL SIGN:
BEFORE Tx: BP:
PR:
RR:
130/90
92
22
DURING Tx: 110/70
BP: 98
PR: 22
RR:
(+) ambulatory
OCCULAR INSPECTION:
(+) mesomorphic
(+) scars on L FA et hand
(+) open wound L palm
(+) skin discoloration on L hand
Pt is C/C/C, alert et oriented as to P/P/T
NEUROLOGIC EXAM:
(+) intact sensation
(+) normothermic
PALPATION:
(+) non-pitting edema on L thenar eminence
(+) normotonic
MUSCLE TONE
ASSESSMENT:
DEEP TENDON REFLEX:
N/A
PATHOLOGIC REFLEX:
N/A
PRIMITIVE REFLEX:
R
REMARKS:
Page 2 of 5
SPECIAL TEST:
N/A
110/70
AFTER Tx: BP: 84
PR: 18
RR:
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DOCUMENTATION CODE: F-MSRMED-008
REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014
Republic of the Philippines
Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER
Department of Rehabilitation Medicine
Capitol Compound Cagayan de Oro City
OUTPATIENT PHYSICAL THERAPY EVALUATION
RANGE OF MOTION AND MANUAL MUSCLE TEST
REMARKS:
ROM and MMT of both UE and LE are WNL and grading except:
ACTIVE
PASSIVE
NORMA
L
CURRENT
ACTIVE
MOTION
Wrist flexion
070
040
060
Wrist extension
MCP flexion
END-FEEL
PASSIVE
R
Firm
3-/5
0-44
0-70
Firm
3-/5
0-75
0-90
Firm
2-/5
SCOR
E
2
2
1
2
2
3
3
2
2
1
20
REMARKS:
COORDINATION & BALANCE TESTS:
GRADE:
LEFT
0-80
TOTA
L
0-76
FUNCTIONAL TEST:
ACTIVITY
BOWEL
BLADDER
GROOMIN
G
TOILET
USE
FEEDING
TRANSFER
MOBILITY
DRESSING
STAIRS
BATHING
MMT
COORDINATION TEST
Finger to nose
Finger to therapists
finger
Finger to finger
Alternate nose to finger
Finger opposition
Rebound phenomenon
Tapping (hand)
GRADE:
RIGHT
REMARKS
N/A
Alternate heel-to-knee;
heelto-toe
Heel-to-shin
Tapping (foot)
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Republic of the Philippines
Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER
DOCUMENTATION CODE: F-MSRMED-008
REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014
Department of Rehabilitation Medicine
Capitol Compound Cagayan de Oro City
OUTPATIENT PHYSICAL THERAPY EVALUATION
BALANCE TEST
Standing in a normal comfortable posture
Standing, feet together (narrow BOS)
Standing in tandem position, with one foot
directly in
front of the other (toe of one foot touching
heel of
opposite foot)
Standing on one foot
Arm position may be altered in each of the
above
postures (i.e., arms at side, overhead, hands
on waist)
Perturbations: displace balance
unexpectedly (while
carefully guarding the patient)
Standing, functional reach: forward trunk
flexion with
UE
reach
Standing, laterally flex trunk to each side
Tandem walking, placing the heel of one foot
directly
in front of the toe of the opposite foot.
Standing in tandem position eyes open to
eyes closed
GRAD
E
REMARKS
N/A
Key to grading:
5
Normal performance
Minimal impairment: able to accomplish; slightly less than normal speed; requires supervision/ minimal
contact guarding
Moderate impairment: able to accomplish activity; movements are slow, awkward, & unsteady;
requires moderate contact guarding
Severe impairment: able only to initiate activity without completion; requires maximal
contact guarding
Activity impossible
POSTURAL ANALYSIS
REMARKS:
Pt. was seen c slight
lumbar lordosis
1
0
1
0
1
0
1
0
5
1
0
Total Score
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55/60
Republic of the Philippines
Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER
DOCUMENTATION CODE: F-MS-RMED008
REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014
Department of Rehabilitation Medicine
Capitol Compound Cagayan de Oro City
OUTPATIENT PHYSICAL THERAPY EVALUATION
GAIT ASSESSMENT/ANALYSIS:
REMARKS:
Pt has N gait pattern
JOINT
INITIAL
CONTACT
MIDSTANCE
PUSH-OFF
SWING
HIP
KNEE
ANKLE
GROSS/MOTOR SKILL ASSESSMENT
REMARKS:
Can perform gross motor skills s difficulty
/A/
PT IMPRESSION:
Pt has difficulty performing L hand movements 2 flexion contracture
PROBLEM LIST: 1. (+) LOM on L wrist et hand
2. mm weakness on L hand
3. poor gripping strength on L hand
LONG TERM GOAL:1. Pt will have a WNL ROM on L wrist flex et ext, et MCP flexion within 12 tx
sessions
2. Pt will have mm strength on L MCP flexors et ext. from 2-/5 5/5 within
12 tx sessions
3. Pt will have mm strength on L wrist flexors et ext. from 3-/5 5/5 within
12 tx sessions
SHORT TERM GOAL:
4. Pt will have an ROM of 10 on L wrist flex et ext, et MCP flexion within 6
tx sessions
5. Pt will have mm strength on L MCP flexors et ext. from 2-/5 3/5 within 6
tx sessions
6. Pt will have mm strength on L wrist flexors et ext. from 3-/5 3+/5
within 6 tx sessions
/P/
PT MANAGEMENT: 1. HMP on L hand x 15 min x 2 sets; done alternately c AAROME
2. AAROME on L hand x 10 reps x 2 sets
3. Stretching on L wrist fl et ext.; finger fl et ext; finger abd/add x 10 reps c
10SH x 2 sets
4. Strengthening ex. on L hand c squeeze ball x 10 reps c 10SH x 2 sets
5. Pt. education
6. HEP
EVALUATED BY:
PHYSICAL THERAPY INTERN
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