2. PATIENT DEMOGRAPHICS
Name: Mr. D
Age: 29 years old
Gender: Male
Address: Tacloban City
Handedness: Right
Civil status: Married
Occupation: Cyclist
Referral: Dr. Kwak
Date of referral: 10/12/19
3. C/c:
pt. c/o dull aching pain in his anterior R knee c a pain
scale of 7/10 NPRS and low back pain c a pain scale of
3/10
4. HPI:
pt. was already experiencing knee pain last May of
2019. On September 28, 2019 while riding his bike he
felt intense knee pain and states pain in the middle
and lower back. The pain vanished after rest. On
October 10, 2019 the pt. went to see a
musculoskeletal specialist and was referred to
Physical Therapy.
5. Pt. Goals: the pt wants to eliminate the pain and go back competing in
cycling. Prior level of function: pt can join cycling competitions. General
health status: rates health as good. Social health habits: (+) smoker, (-)
alcohol (+) exercise. Social hx: Wife & mother-in-law visit regularly.
Living environment: pt lives alone in a small one-level apartment.
Family hx: (+) OA, paternal side. medical/surgical hx: none affecting
current condition. Functional status /activity level: pt reports apart
from the hours of cycling training, he runs a continuous 2 hours a week
on a treadmill, strengthening both the upper and lower train muscles
Medications: pt. takes nonsteroidal anti-inflammatory drugs (NSAIDs) to
reduce pain. Other clinical test: X-Ray: radiography reports indicate
narrowing of the space between the bones of the joint where the
cartilage has worn away.
6. Systems Review
Cardiovascular/Pulmonary system: unimpaired.
HR: unimpared. 40 bpm, L radial artery, palpatory, sitting
RR: unimpaired 14 cpm,
BP: Unimpaired. 120/80 mmHg, L brachial artery, auscultatory, sitting
8. Systems Review
Musculoskeletal system: unimpaired.
Gross symmetry: unimpaired in face, sitting & standing.
Gross strength: Impaired R LE.
Height: 5 ft. & 9 in.
Weight: 70 kgs.
10. Systems Review
Communication style/ability: unimpaired, age-appropriate
communication.
Cognition: unimpaired, pt is oriented x 3 as to place, person, time.
Emotional/behavioral responses: Appear appropriate:
Learning style: Pt learns best through demonstration.
Learning barriers: none.
19. Problem List
1. Dull aching pain in the R knee and Middle and lower back
2. LOM in R Hip flexion and extension and R knee flexion and extension
2 to pain
3. (+) thoracic kyphosis
4. (+) antalgic gait
5. Decrease m. strength in R quads and hamstring muscles
6. Impaired balance
7. Crepitus
20. Prognosis
pt has a good prognosis and will be able to recover near normal
function and return to prior activities p 6 wks of PT rx session
21. PT Dx:
Pattern A Neuromuscular: primary prevention/risk reduction for loss of
balance and falling
23. Long-term Goals:
1. Pt. will be able to regain normal functional movement of R LE c full
ROM, pain free in order for the pt to go back competing in cycling p
6 wks of PT rx session.
2. Pt. will be able to do vocational and avocational activities p 6 wks
of PT rx session.
24. Short-term Goals
1. Pt will increase independence in ambulation and transfers from FIM 6/7 -
> 7/7 p 3 wks of pt rx session to improve fuctional indep.
2. Pt will decrease pain from NPRS of 7/10 -> 4/10 p 3 wks of pt rx session
in preparation for AROM exercise.
3. Pt will increase ROM on R hip flexion and extension, R knee flexion and
extension c an increment of 5 degrees p 3 wks of pt rx sessions to improve
jt. Mobility
4. Pt. ms. strength on R quads and R hamstrings will have an increase in
MMT grade from 3-/5 to 4/5 p 3 wks of pt rx sessions.
5. Pt. will demonstrate increase balance c a Grade of 1 -> 3 & can Tolerate
of at least 45-60 mins [fair (+)] on standing and amb. p 3 wks of pt rx
sessions in preparation for gait training.
25. PT Rx
1. TENS: 10 Hz for 20 minutes in the anterior knee to reduce pain
2. Passive stretching of quadriceps, hamstrings, and adductors. There
are 3 series of 10 repetitions with 30 seconds of stretching.
3. Cryotherapy for 10 minutes, with an ice pack applied to the R Knee.
4. Low Intensity Aerobic exercise – walking for 20 m distance daily to
improve endurance.
5. Resistance Exercise of quadriceps and hamstrings. 2 sets x 10
repetition in a OKC to improve muscle strength
6. Balance training
26. Pt. Education
1. Education about the condition of the patient, prognosis, and POC
2. Postural education to avoid faulty postures such as forward head +
kyphotic posture and shoulder hiking.
3. Proper body mechanics to avoid aggravating pain in the lower back.
4. Educate the pt about the importance of at least 20 mins of exercise
5. Educate the pt about effective strategies to manage problems.
