Physical Therapy Initial Evaluation

Physical Therapy Initial Evaluation
Medical Diagnosis: Dyspnea on exertion
Therapy Diagnosis: decreased functional activity tolerance; low back pain; muscle weakness; impaired functional mobility; gait
abnormalities
Insurance: Tenncare - UHC
Recommendation: Physical therapy 2x/week for 5 weeks with reassessment to follow.
Subjective: Pt is a 63 y.o. female who presents to MHN OP PT clinic with dyspnea on exertion, decreased functional activity tolerance
and low back pain.
HPI: Pt referred from Dr. Dishmon’s MD outpatient office after follow-up secondary to hospitalization in November of 2018. Pt admitted to
MHN on 11/18/2018 with SOB and cough. Cardiology was consulted for chest pain and increased troponins. However, based on
negative stress test and history of elevated troponins (both tests performed in June 2018), cardiology determined chest pain were result
of pleuritic cough. Per Cerner report, echocardiogram performed in October 2017 showed mild left ventricular hypertrophy with a left
ventricular ejection fraction of 65%, normal regional wall motion, abnormal diastolic function and no significant valvular disease. Once
medically stable, pt discharged home and upon follow-up with cardiologist on 12/11/2018 who referred pt to OP PT.
PMHx: . Diabetes mellitus, Hypertension, Chronic obstructive pulmonary disease, Allergic rhinitis, Obesity, Hyperlipidemia, Coronary
artery disease, Gastroesophageal reflux disease, Obstructive sleep apnea, Cardiomyopathy.
Impairments: Pt’s greatest problems include decreased functional activity tolerance with SOB as well as low back pain. Pt states she is
unable to ambulate greater than 5mins without increased SOB and needing a seated rest break secondary to fatigue and low back pain.
Pt also states ascend/descend 1 flight of stairs is very challenging and she needs to rest halfway through. Denied use of supplemental
O2 during the day, but occasionally uses 2L of supp O2 via NC for about 30mins in the middle of the day and uses CPAP and 2L of supp
O2 every night. Pt denied dizziness, lightheadedness, and headache throughout evaluation. Pt states low back pain at rest is 4/10 and
increases to 7-8/10 with prolonged standing and walking. Denied paresthesias throughout evaluation, but reports intermittent B foot
paresthesias especially at night. Pt states she is IND with ADLs but is unable to participate in cooking/cleaning and going to church
without complaints of fatigue, SOB or increased LBP.
Social Hx/DME: Pt lives in 2-story home with daughter and grandson in 13 steps to second floor. Pt is on disability and does not plan to
return to work as day-care provider. DME includes SPC. She enjoys reading and going to church. Pt does not drive and relies on
transportation.
Pt Goals: 1. "Stop hurting and breathe better"
The following personal factors and comorbidities relate to the complexity of this patient ’s presentation and will likely impact the POC:
1. History of HTN, CHF, COPD and related comorbidities
2. Transportation
Objective: R hand dominance
AROM: MMT:
L LE R LE L LE R LE
Hip flexion 120 120 4/5 4/5
Hip abduction 45 45 3/5 3/5
Hip extension NT NT NT NT
Hip IR NT NT NT NT
Hip ER NT NT NT NT
Knee extension 0 0 5/5 5/5
Knee flexion 120 120 4/5 4+/5
Ankle DF 10 10 4-/5 4+/5
Ankle PF 40 40 5/5 5/5
p! = pain reported
Sensation: Dermatomes for light touch in tact for BLEs.
Edema: 1+ pitting edema in R LE and 2+ pitting edema in L LE - measured 4inch above malleoli
Functional Mobility:
Supine<>sit: NT
Sit<>stand: SPV Pt able to perform with no UE support
Gait: 80 feet, no AD, CGA Demonstrates significant lordosis and increased lateral trunk sway to
R side secondary to LBP; demonstrates decreased B hip extension
in terminal stance, slight L circumduction, and slight decreased R
knee flexion in swing phase
Stairs: NT
TUG (no AD): Trial 1) 10.72s – Pt is at increased risk for falls as age-related norm is 8 seconds.
5xSTS: 12.91s – Pt is at slight increased risk as cutoff for fall risk is >12 seconds and age-related norm is 11.4 seconds.
6 minute walk test (no AD): 179.5 meters (605 feet)

Pt reported increased LBP after 2:30sec followed by decreased cadence and decreased B step length. Pt became SOB after ~3
minutes but O2 sats measured at 98% on room air and HR 100bpm. Pt took one standing rest break during test at 4:45sec for 20
secs and VC given for diaphragmatic breathing.
Based on test, pt falls below the age-related norm of 538 meters, indicating significant decrease in functional activity tolerance.
Balance:
Static sitting balance: Good Pt able to maintain postural control throughout sitting assessment.
Dynamic sitting balance: NT
Static standing balance: Good Pt able to maintain postural control throughout standing assessment.
Pt did complain of LBP after several minutes of standing.
Dynamic standing balance: NT
The following impairments have been identified and will be addressed in the POC outlined below:
Body functions/structures/systems – ms weakness, decreased functional activity tolerance, SOB, gait abnormalities, LBP
Activity limitations/Participation restrictions – Pt unable to ambulate for >5 minutes without increased pain and SOB, unable to stand for
>5 minutes without increased pain and SOB, unable to attend church, unable to clean her house "the way she likes it", unable to
ascend/descend 13 steps without significant fatigue requiring rest break and SOB.
Today's Tx: Evaluation completed. PT discussed OP PT POC and goals with pt who was in agreement with plan.
Assessment: Pt presents to OP PT with dyspnea upon exertion, LBP, and muscle weakness causing significant decreased functional
activity tolerance, decreased functional mobility, and inability to carry out ADLs. Pt is considered at slight increased risk for falls based
on TUG. Pt would benefit from skilled PT intervention to decrease LBP pain, increase strength, and improve functional activity tolerance
to ensure independence and safety during all ADLs, iADLs, and gait.
The patient’s current clinical presentation has evolving characteristics.

Overall, based upon the patient’s history, the objective examination, and clinical presentation, pt is of moderate complexity.
Plan: Plan of care to include the following:

1. Modalities as needed for pain modulation, including US and e-stim.
2. Therapeutic exercise to increase strength.
3. Manual therapy to improve AROM, strength, and reduce pain.
4. Patient education to allow for improved results during treatment and maintenance of OP PT goals.
5. Therapeutic activity to increase tolerance/decrease assistance needed for functional tasks and ensure safety.
6. Gait training to allow for improvements in gait mechanics/speed and ensure safety.
Long-term goals/goals to be met at discharge:

1. Pt will be IND and compliant with HEP.
2. Pt will increase B hip abduction, B knee flexion, and B hip extension by at least ½ grade on MMT in order to improve mobility and
function for ADLs.
3. Pt will improve TUG to <8 seconds in order to be within age-related norm and be at decreased risk of falls.
4. Pt will improve 5x sit-to-stand to <11.4 seconds in order to be within age-related norm and increase functional mobility.
5. Pt will improve 6-minute walk test to at least 270 meters in order to increase functional mobility and ensure safety for community
ambulation.
6. Pt will be able to ascend/descend 20 stairs using reciprocal stair pattern,1 handrail with SPV and no rest breaks to increase
functional mobility and ensure safety for ambulation.
7. Pt will be able to ambulate 250 feet with decreased R lateral trunk lean and decreased L circumduction 80% of the time in order
to ensure safety with mobility.
Thank you, Dr. Bishom , for your referral and for allowing me to participate in Ms. Weeams's rehabilitation. I will keep you informed of
her progress.
Time Began: 0900

Time End: 1000

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Physical Therapy Initial Evaluation

Medical Diagnosis: Dyspnea on exertion

Insurance: Tenncare - UHC

Recommendation: Physical therapy 2x/week for 5 weeks with reassessment to follow.

Pt Goals: 1. "Stop hurting and breathe better"

Objective: R hand dominance

Sensation: Dermatomes for light touch in tact for BLEs.

6 minute walk test (no AD): 179.5 meters (605 feet)

The patient’s current clinical presentation has evolving characteristics.

Plan: Plan of care to include the following:

Long-term goals/goals to be met at discharge:

Time Began: 0900

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