Initial Evaluation

GENERAL INFORMATION:
Patients Name
: J.M.
Age
: 22 y/o
Sex
: Male
Address
: Cabaroan Zone 6, City of San Fernando La Union
Civil Status
: Single
Handedness
: Right
Occupation
: NONE
Religion
: Roman Catholic
Referring Unit
: O.P.D
Attending M.D.
: Dr. E
Date of Admission
: January 15, 2016
Date of Evaluation
: January 17, 2016
Diagnosis
: Grade 2 (R) ankle sprain
S:
c/c: masakit ang kanang paa ko (pointing his (R) ankle) kapag sinusubukan
kong ilakad at igalaw (PS of 5/10) at nawawala ang sakit kapag hindi ko
ginagalaw.
Pt. Translate: Pt. c/o constant aching pain on (R) ankle c a PS of 5/10 when
he tries to weight-bear into his (R) LE and felt pain free when at rest.
HPI:
Pt. present condition started last January 14, 2016 when he is playing
basketball. Pt. stated that when he rebound the ball, he landed to his
opponent (L) feet and got outbalanced, he felt localized constant aching pain
into his (R) ankle c PS of 8/10 and cannot stand independently, his team
mates helped him to stand up and went him to the bleachers. He
immediately applied icing into his (R) ankle to prevent swelling and decrease
the pain (PS of 7/10).
When he wakes up in morning (Jan. 15, 2016), his (R) ankle still in pain
and he decided to have a checked up in Bethany Hospital. Dr. E requested
him to undergone X-ray (see AP) and p that, Dr. E apply bandage in to his (R)
ankle and instructed him to take medicine (see medication) and not to move
or weight bear his (R) leg.
Ancillary Procedure:
Diagnostic imaging
X-ray

Medications:
Medication
Mefenamic Acid
PMHx: Unremarkable

Result
(+) ankle sprain

Dosage
Every 4 hrs. As needed

Indication
Pain

FMHx:
Htn
Arthritis
DM
Heart dse.

Mother
(-)
(-)
(-)
(-)

Father
(+)
(+)
(-)
(-)

PSEHx:
Pt. lives in a semi-concrete bungalow with his parents and brother. Pt
has no hx of substance abuse and is an occasional alcohol beverage drinker,
a smoker with 5 sticks per day. Pt. sleeps in a sofa bed in supine position. At
present, pt. stopped smoking, drinking alcohol beverages and now lives a
sedentary lifestyle, doesnt play basketball anymore, d/t his present
condition.
House Dimension:
Main door <-> BR: 5 m
BR <-> CR: 3 m
BR<-> kitchen: 4 m
Goal: Gumaling na sana ang kanang paa ko para magawa ko na yung mga
gusto kong gawin katulad ng pagbabasketball at makatulong sa mga gawaing
bahay
O:
VS:

OI:

BP: 140/80 mmHg

PR: 70 bpm
RR: 17 cpm
Temp.: 37.1 C
Manner of arrival: Amb. s AD
Mental status: A/C/C
Physique: Ectomorph
(+) Elastic Bandage on (R) ankle
(+) Trophic Skin Changes (Red in color)
(+) swelling on (R) ankle
(+) Gait deviation (See GA)
(-) bruising
(-) Others

Palpation:
Thermal assessment: Hyperthermic on (R) ankle
Tone assessment: Normotonic on (B) UE/LE
(+) Tenderness grade 2 on (R) ankle
(-) Edema
(-) others
Neurologic Examination
Sensory Testing:
Device used: brush for light touch, thumb for deep pressure

Findings: intact sensory pathway on (B) UE/LE

Sig: For Baseline Data
DTR:
Legend:
0 Areflexia
+ Hyporeflexia
++ Normoreflexia
+++ Hyperreflexia

Findings: pt. is normoreflexive on (B) UE/LE

Sig: intact reflex arc
ROM:
Findings: All jts. of (B) UE/LE are actively and passively done WNL
pain free c N EF except as follows:
Motion
Activ Passiv Norm
Differences
Endfeel
e
e
al
Active
Passiv
e
Ankle DF
0-3
0-11
0-20
17
9
Empty
Ankle PF
0-23o
0-31o
0-50o
27o
19o
Empty
o
o
o
o
o
Ankle Inversion
0-10
0-17
0-35
15
18
Empty
Ankle Eversion
0-4o
0-10o
0-15o
0-11o
0-5o
Empty
Sig: LOM 2 to pain
MMT:
Findings: All major (m) of (B) UE/LE are grossly graded 5/5 except for:
Motion
Grade
(R) Ankle Dorsiflexors & Plantar
3-/5
Flexors
(R) Ankle Invertors
3-/5
(R) Ankle Evertors
3-/5
Sig: (m) weakness 2 disuse
ST:
(+) Anterior Drawer Test of the ankle
Sig.: ATF (ant. Talofibular) ligament sprain

PA:
Findings: Postural landmarks are assessed in ant., post., and lat.
views in standing position and are found to be in N alignment.

Sig.: For baseline data

G.A:
Findings: No heel strike on the (R) foot
Sig: 2 to antalgic gait pattern
Functional Analysis:
ADLs
Self-care
Feeding: 7
Grooming: 7
Dressing: 6
Bathing: 7
Toileting: 7
Bed mobility
Roll to right: 6
(<25%)
Roll to left: 7
Supine to sit: 6
Sit to supine: 6
Transfer
Bed to chair: 7
Sit to stand: 7
Ambulation: 6

FIM LEVELS
No Helper
7 - Complete Ind.
6 - Mod Ind.
5 - Min Ind. (subject 100%)
4 - Modified Dep, Min. Asst (75%)
3 - Modified Dep, Mod. Asst (50%)
2 - Complete Dep, Max Asst (25%)
1 - Complete Dep, Total Asst

Sitting/ Standing Balance Tolerance

Balanc Toleranc
Legend:
e
e
(mins.)
Sitting
N
>60 min
0
Standin
F
~10 min
P
g
F
+
+
G
+
+
+
N
+
+
+

Assume

Maintai
n

Weight
-Shift

Challeng
e

A:
PT Impression: A 22 y/o male c/o localized constant pain on his (R) ankle
resulting to difficulty in ambulation and cannot do his ADLs normally such
household chores. Because of his injury, he cannot do his recreational
activities such as playing basketball.
Procedural Intervention: PT proposes restorative intervention c 3 tx
sessions per wk. for 1 month.
Rehabilitation Prognosis: Pt. has an excellent prognosis as to rehab.
because he is still young and energetic and also has a good financial support.

Problem List
1. Pain on his (R) ankle c
a PS of 5/10
2. Gr. 2 tenderness on
the (R) ankle
3. Swelling

STG
(
6
Tx
Sessions)
To decrease the pain
by 5/10 to 3/10 p 2
weeks
To decrease the
tenderness
To decrease the
swelling to near
normal p 2 weeks

LTG
(
12Tx
Sessions)
To eliminate the pain
in to his (R) ankle p
1 month
to eliminate the
tenderness p 3
weeks
To eliminate the
swelling p 3 weeks

P:
Suggested Mx:
1. R.I.C.E
Precaution:
Fall
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