INITIAL EVALUATION

02/14/23

Name: Fidelpo, Dumagan Living Environment: Pt lives in a 1 floor apartment c

Age: 66 y.o. 200 sqm lot area; c 10 steps from gate front
Gender: Male door; living room bedroom ~ 12 steps; bedroom
Address: Tres de Mayo, Digos City bathroom ~ 10 steps; House has tiled flooring on
Birthday: 02/08/1957 all areas.
Handedness: R Family Health History:
Occupation: Retired Supervisor at LYR Furniture Condition Pt Mother Father
Store DM + + +
Religion: Roman Catholic CVD - + -
Nationality: Filipino HTN + - -
Civil Status: Married OA - - -
Language: Tagalog, English, Bisaya RA - - -
Type of pt: OPD Sig: Pt presents c type 2 diabetes mellitus et HTN
Referring MD: Unrecalled that may hinder rehab potential
Rehab MD: Dr. Tuason Social Health Habits: Pt prefers vegetables on a daily
Eval Date: 02/14/23 basis; Rarely exercises at home et is mostly
Dx: L Below Knee Transtibial Amputation sedentary; p amputation surgery, pt stopped eating
S: unhealthy viands et does home exercises daily; (-)
C/C: Pt states “Maglisod ko ug lakaw gamit akong smoker
walker padulong sa sala ug kwarto kay walay kusog Medications:
akong L nga tiil”
Medicine Dosage Indication
HPI: Pt is a type 2 diabetic for unrecalled years et
Metformin Unrecalled DM
complied to antidiabetic medication such as
Insulin Unrecalled DM
Metformin and Insulin shots daily; However, on year
Medical/Surgical Hx:
2020, pt noticed that his L LE became progressively
Condition Date Procedure
discolored et developed gangrene; Blisters were
observed on B LE et dry, blotchy skin was observed Cataract 2016 Laser surgery
for unrecalled months; Pt had a hard time for cataract;
ambulating c L LE et loss partial sensation on Resolved
affected region; Next the family et pt opted for Gangrene on L 2020 L Transtibial
surgery in order to save the L LE et pt undergone 1 st LE Amputation;
long below knee transtibial amputation surgery at Resolved
Digos Doctors Hospital by unrecalled surgeon; p 5 Other Ancillary Procedures: Pt has not recalled any
days infection spread proximally et was advised to ancillary procedure done
do 2nd medium below knee surgery; pt was admitted Current Level of Function: Pt is unable to do indep
another week in order to prevent another infection; ambulation c walker for prolonged period of time;
Stump healing took pt did not do any exercise for 2 Max difficulty in doing household chores such as
years et had sedentary lifestyle;; Pt only took cleaning the floor s assistance d/t LOM on R hip
antidiabetic medications et does not consistently flexion, L hip flexion, L hip extension, L abduction, L
bandage L distal stump; Pt went to MCDC Hospital knee flexion, et L knee extension et ms strength on
for consultation c Dr. Tuason et was advised for R hip flexors, L hip flexors, L hip extensors, L
Physical Therapy Rx for deconditioning et training for abductors, L knee flexors, et L knee extensors
prosthesis as outpatient 3x a week for 9 sessions. O:
Prior Level of Function: Pt was amb dep et using Systems Review:
wheelchair as means of amb since 2018; Unable to Cardiovascular System: Impaired
do community amb, ADLs, et self-care activities s BP: a: 130/80 mmHg; L brachial artery;
pain, difficulty, et assistance from wife auscultation sitting; Stage 1 HTN
Pt’s goal: Pt states “Gusto ko maka gamit ug walker p: 135/85 mmHg; L brachial artery;
ug tarong nga dili ko dali kapuyon” auscultation sitting; Stage 1 HTN
Social Hx: Pt lives c wife et 9-year-old child; Family is PR: a: 68 bpm; L index finger; pulse
supportive of Rx et helps pt c household chores et oximeter; normal supine
ADLs p: 75 bpm; L index finger; pulse
 INITIAL EVALUATION
02/14/23

oximeter; normal supine Learning Barriers: Pt is unable to hear well d/t

HR: a: 75 bpm; L 5th ICS; auscultation; impaired hearing
sitting; normal Learning Needs: Pt needs to learn more on proper
p: : 82 bpm; L 5th ICS; auscultation; bandaging of L stump et needs to practice home
sitting; normal strengthening exercises; Pt needs to be educated of
RR: a: 17 cpm; OI; diaphragm; supine; insulin use to exercise schedule
eupnea Test & Measures:
p: 17cpm; OI; diaphragm; supine; OI:
eupnea Amp Indep c Walker
Temp a: 35.5 C; L axilla; digital thermometer; Mesomorph
: supine; normal (+) Postural Deviations
SPO2 a: 96%; L index finger; pulse oximeter; a. Forward head
supine; normal b. B rounded shoulders
(+) L unilateral transtibial amputation
Integumentary System: Impaired (+) Surgical scar on L distal stump ~ 3.7”
Integrity: Intact (+) Discoloration on L distal stump et R LE
(+) 3.8 in incision scar on L distal stump (+) Scars on R LE
Color: Impaired (+) Edema on L distal stump
(+) Discoloration on R LE et L distal stump (+) Dry/Scaly skin on L distal stump et R LE
(+) Scars on B LE (+) Bandage on L distal stump
(-) Bruises on B LE (-) Pressure Ulcers
Turgor: Unimpaired Palpation: Normothermic on all exposed areas
(-) Skin Turgor Test (+) Taut Band on L hamstrings
Texture: Impaired (-) Tenderness
(+) Dry skin on B LE ROM: All joints of B UE et LE were grossly assessed
Musculoskeletal System: Impaired pain-free et WNL, except:
Gross Symmetry: Impaired on hip et knee motions Joint AROM PROM N A P END
d/t B LE ms strength et LOM Motion FEEL
Gross ROM: Impaired d/t LOM on R hip flexion, L hip R Hip 0°-65° 0°-75° 0°- 35 45° Firm
flexion, L hip extension, L hip abduction, L knee Flexion 120° °
flexion, et L knee extension L Hip 0°-50° 0°-40° 0°- 70 80° Firm
Gross MMT: Impaired d/t ms strength on R hip Flexion 120° °
flexors, L hip flexors, L hip extensors, L hip abductors, L Hip 0°-15° 0°-20° 0°-40° 25 20° Soft
L knee flexors, et L knee extensors Extension °
Height: 5 ft 6 inches L Hip 0°-8° 0°-12° 0°-20° 12 8° Soft
Weight: 81 kgs (180 lbs) Abduction °
BMI: 29.1; overweight L Knee 0°-80° 0°-90° 0°-90° 55 45° Soft
Legend: Flexion °
Underweight: < 18.5 L Knee 80°-0° 90°-0° 135°- 75 65° Soft
Normal weight: 18.5 – 24.9 Extension 20° °
Overweight: 25.0 – 29.9 Sig: Pt presents c LOM on R hip flexion, L hip flexion,
Obesity: > 30 L hip extension, L hip abduction, L knee flexion, et L
Neuromuscular System: Impaired knee extension d/t ms tightness
Gait: Impaired MMT: All muscle groups of B UE et LE were grossly
Locomotion: Impaired assessed et graded 5/5, except:
Balance: Impaired Muscle Group Grading
Motor Function: Unimpaired R Hip Flexors 3-/5
Motor Control: Unimpaired L Hip Flexors 3-/5
Communication Style: Unimpaired; Age-appropriate; L Hip Abductors 3+/5
Pt converses well L Hip Extensors 2+/5
Affect: Pt is positive et cooperative in eval et Rx L Knee Flexors 4/5
Cognition: Unimpaired; Oriented 3x; alert
 INITIAL EVALUATION
02/14/23

L Knee Extensors 2+/5 Thoracic B symmetry B symmetry Increased

Sig: Pt presents c ms strength on R hip flexors, L of nipple of scapula Kyphosis
hip flexors, L hip extensors, L hip abductors, L knee Lumbar Navel in Spine in Decreased
flexors, et L knee extensors d/t ms disuse midline midline Lordosis
Special Test Pelvis Symmetrical Symmetrical Neutral
Name Stimulus Result ASIS PSIS
Hamstring Pt is in long (+) Inability to Sig: Pt presents c forward head posture et B rounded
Contracture sitting et actively reach toes; shoulders
Test reaches his toes Tightness of MBM:
hamstrings 5 inches above patella L R DIFF
Thomas Test Pt is in supine c (-) (Quads):
lumbar spine Contralateral
stabilized et flexion of hip;
flexes Tight hip 15.75 16.5 0.75
contralateral hip flexors in in in
to abdomen Sig: Pt presents c significant LGM discrepancy on L LE
Ely’s Test Pt is in prone (-) Ipsilateral compared to R LE
position et flexion of hip; Stump Measurements
examiner Tight Rectus Landmark: Mid Patella L
passively flexes Femoris Length: 5.5”
pt’s knee 2”: 12.75”
Sig: Pt presents (+) hamstring tightness 4”: 12”
Ax Tools: Sig: Pt presents c dumbbell shaped L distal stump
1) Berg Balance Tests and Rating Scale A:
Score: 11/56 PT diagnosis: Pt presents c locomotion ambulation,
Sig: Pt presents c max difficulty in sitting et standing to sitting, et transfers; Presents c LOM on R
standing, standing unsupported, transfers, hip flexion, L hip flexion, L hip extension, L hip
standing c eyes closed, standing c feet together, abduction, L knee flexion, et L knee extension; Also
reaching forward c outstretched arm while presents c balance problems d/t amputation et
standing, picking up objects from floor, turning walker use
360°, standing on one leg et mod difficulty in Pt prognosis: Pt presents c poor rehab potential in
standing, to sitting, et standing unsupported; Pt terms of returning to function since pt eats healthy
will require a form of amb aid (cane, walker, food et stopped drinking alcohol et has an MMT
etc.) grade of 4/5 on L knee flexors; Pt does not have
2) Amputee Mobility Predictor Assessment respiratory disease et is (-) smoker; The ff are
Tool (AMPnoPRO) possible hindrances to rehab potential such as old
Score: 17/80 (21.3% of functional ability) age of 66 y.o., has impaired hearing which is a
Sig: Pt has a AMPnoPRO score of 7/39 which learning barrier; Has a sedentary lifestyle, had a
indicates that the pt is under k0 functional level; previous stroke attack last 2018 which caused ms
does not have the ability to transfer et ambulate strength on L UE et LE, has LOM on R hip flexion, L
safely s assistance et does not warrant a hip flexion, L hip extension, L hip abduction, L knee
prescription for prosthesis flexion, et L knee extension; Has a MMT grade on
Postural Assessment: Sitting R hip flexors, L hip flexors, L hip extensors, L
Body A View P View L View abductors, L knee flexors, et L knee extensors; Has a
Part Berg Balance Scale of 11/56; Has Type 2 Diabetes
Head Midline c Midline c Forward which is controlled by medication; (+) Malformation
thorax spine head of L distal stump which hinders pt from prosthesis
Neck Midline c Midline c Forward fitting
thorax spine head
Shoulde L=R L=R B rounded
r acromion acromion shoulders
 INITIAL EVALUATION
02/14/23

2. Pt will have mod min difficulty in transfers

Problem List c Berg Balance score of 0/4 2/4 p 2-3
Impairments: weeks of Rx
1. LOM on R hip flexion, L hip flexion, L hip 3. Pt will have mod min difficulty in transfers
extension, L hip abduction, L knee flexion, c Berg Balance of 2/4 3/4 p 2-3 weeks of
et L knee extension Rx
2. Ms strength on R hip flexors, L hip flexors, Participation Restriction
L hip extensors, L abductors, L knee flexors, 1. Pt will have max mod difficulty in
et L knee extensors ambulation within the house c Berg Balance
3. Edema on L distal stump of 11/56 16/56 p 2-3 weeks of Rx
Activity Limitation:
1. Pt has max difficulty in standing P: Pt will be treated 3x/week:
unsupported c Berg Balance score of 0/4 1. AROM on R LE on all planes x 10 reps x 2
2. Pt has max difficulty in sitting to standing c sets; supine
Berg Balance score of 0/4 2. AAROME on L LE on all planes x 10 reps x 2
3. Pt has mod difficulty in transfers c Berg sets; supine
Balance score of 2/4 3. Single Leg Pelvic Bridges x 10 secs hold x 5
Participation Restriction; sets; supine
1. Pt has max difficulty in ambulating within 4. Sit Stand x 10 reps x 3 sets
the house c Berg Balance of 11/56 5. Amb on Walker x 2 rounds
Goals 6. HEP
Impairments: a. AROM on R LE on all planes c ankle
1. Pt will LOM on: weights x 10 reps x 2 sets
a. R hip flexion c an increment of 15° p 2- b. AAROME on L LE on all planes x 10 reps
3 wks of Rx x 2 sets
b. L hip flexion c an increment of 10° p 2-3 c. SLR on B LE x 10 secs hold x 2 sets
wks of Rx Suggested PT Rx:
c. L hip extension c an increment of 5° p 1. Amb on uneven surfaces c walker x 5
2-3 wks of Rx rounds
d. L hip abduction c an increment of 5° p 2. Strengthening on B UE c 3lb dumbbell on all
2-3 wks of Rx motions x 10 reps x 2 sets
e. L knee flexion c an increment of 10° p -----------------------Nothing Follows--------------------------
2-3 wks of Rx
f. L knee extension c an increment of 10°
p 2-3 wks of Rx Conelle Michaele M. Zapanta
2. Pt will ms strength on: SPC PT - Intern
a. R hip flexors from MMT of 3-/5 3+/5 p
2-3 weeks of Rx
b. L hip flexors from MMT of 3-/5 3+/5 p
2-3 weeks of Rx
c. L hip abductors from MMT of 3+/5
4/5 p 2-3 weeks of Rx
d. L hip extensors from MMT of 2+/5
3+/5 p 2-3 weeks of Rx
e. L knee flexors from MMT of 4/5 5/5 p
2-3 weeks of Rx
f. L knee extensors from MMT of 2+/5
3-/5 p 2-3 weeks of Rx
Activity Limitation:
1. Pt will have max mod difficulty in
standing unsupported c Berg Balance score
of 0/4 2/4 p 2-3 weeks of Rx