LORMA COLLEGES

Carlatan, San Fernando City, La Union

College of Physical and Respiratory Therapy

In Partial Fulfillment for the requirements in Clinical Education

Initial Evaluation

Submitted to:
Ms. Teresa Rose Combalicer, PTRP

Submitted by:
Bisquera, John Glenn
Cruz, Wenzy Razzie
Flores, Paul John
Reyes, Dante Jr.

Agra, Crissa Julienne

Anin, Jerna

Cario, Pauline Trisha

Estacio, Patricia Ashley
Garcia, Jennie Ross

August 31, 2016

INITIAL EVALUATION

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

DATE & PLACE

FINDINGS

X-ray
(oblique view)

08-23-16
LMC

Total tear of the lateral

ligaments

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

Attachment: (+) bandage on R ankle

(+) swelling on R ankle
Palpation:
(+) Gr. 3 tenderness on R ankle
(+) swelling on R ankle
(-) edema
ROM:

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)

Sig: Pt. was N/A 2 to pain and swelling

MMT:

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

Significance: Not assessed d/t pain upon movement

ST:
(+) Squeeze Test
(+) Ant. Drawer Test
Findings: Tear on the lateral ligaments of the ankle
DTR:

Legend:
0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

Findings: Normoreflexive on B UE and LE except Achilles Tendon Reflex (N/A)

2 to pain upon movement
PA:
(R) hip higher than (L) hip
Significance: 2* to grd. 3 ankle sprain
GA:
Pt. is amb on level surface with B crutches c min.-no assist using the swing through gait
pattern
Stance Phase:

IC

(+)

(+)

LR

(+)

(-)

MS

(+)

(-)

TS

(+)

(-)

Findings: antalgic gait

Significance: 2 to ankle sprain
A:
Rehabilitation Potential: Excellent
Prognosis: Good
PT Impression:
A 27 y/o M has difficulty on ADL such as ambulating and lower garment dressing
using affected R ankle d/t pain 2 to gr.3 ankle sprain. He is dependent in amb. c AD

(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

LTG (24 Tx sessions)

To eliminate pain on R ankle

STG (10 Tx sessions)

To pain on R ankle from

9/10
2. Swelling on R ankle

w/n 6 wks.
To eliminate pain on R ankle

9/10 to 5/10 w/n 3 wks.

To swelling on R ankle w/n

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

ankle w/n 6 wks.

To perform ADL

from Gr.3 to Gr.1 w/n 3 wks.

To perform ADL

independently s the use of

independently s the use of

independently s the use of

AD (bilat. crutches)

ADs (bilat. crutches) w/n 6

ADs (bilat. crutches) w/n 3

5. Unable to perform

wks.
To be able to amb.

wks
To wt bearing on R ankle

independent amb. s AD (bilat.

independently s ADs (bilat.

w/n 3 wks.

crutches)

crutches) w/n 6 wks.

P:
PT Mx:
1.
2.
3.
4.

US x 1.25w/cmx5 on R ankle to relieve pain, swelling and promote healing

HMP x 15 to R ankle for immediate pain relief
Gentle mobility exercise x5/wk to restore full ROM
Jt. mobilization on R ankle x5/wk. 2 sets, gr.1 small amplitude oscillation to
prevent LOM