INITIAL EVALUATION

GENERAL INFO:
Pt Name
Age
Sex
Address
Civil Status
Handedness
Occupation
Religion
Attending Doctor
Date of IE
Diagnosis

: R.M.M.
:56 y.o.
:M
: Ili Norte, San Juan, La Union
: Married
: Right
: Provincial Administrator @ La Union Capitol
: R.C.
: Dr. A.L.
: Nov. 19, 2016
: Poliomyelitis

S:
c/c: Sobrang mahirap umakyat at bumamaba nang hagdan tsaka maglakad sa
tuyo na buhangin pati sa mga may carpet. Bumabaon kasi yung paa ko. Mabilis na
nangangalay yung kanang bewang ko kapag matagal na akong nakatayo. pt.
verbatim
PT Translation: Pt. has max. difficulty in ascending and descending the stairs and
walking on a sandy terrain as well as carpeted floors. Pt. feels weary on his R hip
upon prolonged standing.
HPI: Present condition started when the pt. was 1 year and 8 mo. old, one night
the pt.s mother noticed that the pt. had a very high fever and was very irritable.
The pt. was rushed to L.C.H. and was attended by Dr. A.L. who immediately
suspected poliomyelitis and instructed the mother to return the pt. the following
night if the pt. was still presenting the symptoms. Upon returning to the hospital,
the pt. was subjected to a spinal injection (unrecalled) p the injection the pt.s fever
and irritability went down gradually. The Dr. explained the possible deformities that
might occur in the following years
When the pt. was 2 y.o., the mother noticed a discrepancy on the L and R
extremity when carrying the pt. The pt. has lived with his condition ever since s any
therapy.
At present, the pt. uses a cane for assistance during ambulation and has
difficulty with walking on uneven and slippery terrains and standing for a prolonged
period of time.
PMHx:
(+) Surgeries for Cellulitis on the skin over the Achilles tendon
(June 27, 2016 @ M.C.)
(July 16, 2016 @ M.C.)
(August 12, 2016 @ L.M.C.)
(+) Blood Culture Screening (June 27, 2016 @ M.C.)
Findings: Localized infection
(+) HTN
(+) DM
(-) Asthma
(-) Heart dse.
FMHx:
HTN

FATHER
(+)

MOTHER
(-)

DM
Heart Dse.
Asthma

(+)
(-)
(-)

(-)
(-)
(-)

PSEHx:
Pt. is non-alcoholic and a non-drug user. However, pt. smokes about half a
pack daily. (17 pack years)
Pt. lives c his wife, 2 children and a helper in a two-storey house. Pt.s bed
room is situated on the second floor; the pt. only goes up once around 9:00 P.M.
when he feels drowsy because ascending the stairs is difficult. Pt. lies on a firm
mattress, positioned ~ 2 in. below his knee. Pt. lies in supine when sleeping. The
stairway is composed of 10 steps, ~ 9.5 in. tall/riser. BR CR ~10 steps, BR
Kitchen ~40 steps, BR Main door ~43 steps. Main door Gate ~ 13 steps.
Pt. lives a sedentary lifestyle, a type B personality. Pt. has no specific
preference in food.
Goal: Gusto ko kahit papaano, makatagal akong makatayo at makalakad.
O:
VS:
BP:
PR:
RR:
To:

130/80 mmHg
80 bpm
25 cpm
35.6 C

OI:
Manner of Arrival: Amb c AD (cane)
Mental status: A/C/C
Physique: Mesomorph
(+) postural deviations (see PA)
(+) atrophy on (L) thigh and leg
(+) hypertrophy on thigh and leg
(+) L Claw foot
(+) L overlapping toes
(+) bandage around L ankle
(-) Trophic skin changes
(-) swelling
Palpation:
Thermal Assessment: Hypothermic in all exposed body parts
Tone Assessment: Normotonic in all exposed body parts
(-) Tenderness
(-) Muscle Spasm
(-) Edema
(-) Tightness
ROM:
Findings: Motions of the L Hip joint and Knee joint were not assessable 2 to
atrophy of the muscles
Motions of (B) UE, (R)LE, neck and trunk were assessed actively, painfree and are WNL except for the ff:

Motion

AROM

PROM

NORMA
L

Differen
ce
(AROM)

Differen
ce
(PROM)

END
FEEL

(L) Ankle
FIRM
0 - 40
0 - 40
0 - 50
10
10
PF
(L)
FIRM
0 - 10
0 - 17
0 - 20
10
3
Ankle DF
(L) Ankle
FIRM
0 - 28
0 - 20
0 - 35
7
15
eversion
(L) Ankle
HARD
0 - 2
0 - 12
0 - 15
13
3
inversion
Sig: LOM to ankle plantar flexion, dorsiflexion, eversion and inversion 2 to
weakness.
MMT:
Findings: All major (m) o (B) UE&LE are measured using the break test and
are grossly graded 5/5 except for
Muscle Group
Hip flexors
Hip extensors
Hip abductors
Hip adductors
Knee flexors
Knee extensors

(L)
5
5
5
5
5
5

(R)
0
0
0
0
0
0

Sig: No palpable muscle

contraction on hip and knee
2 to denervation

Neurologic Examination:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for P.
Findings: Pt. has intact sensation as to pain, light touch and pressure
Significance: for baseline data

DTR:
(R)

(L)
+
+

+
+
++
++
+

++

++
++

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

Findings:
Pt. is areflexive on L LE and hyporeflexive on R knee.
Sig: Broken reflex arc 2 to affectation of the lower motor neurons.
Pathologic Reflexes:
Findings:
(-) Babinski Test
(-) Gordons Test
Sig: No affectation on the upper motor neurons.

ANTHROPOMETRIC MEASUREMENT:
MUSCLE BULK MEASUREMENT:
Findings:
LANDMARK
4 above from
knee
4 below from
knee

RIG
HT

LEFT

DIFFERE
NCE

21

14

16

11.5

4.5

Sig.: Atrophy of L thigh and leg muscles 2 to denervation

LEG LENGTH MEASUREMENT:
Findings:
Landmark
TLL

ALL

ASIS to
medial
malleolus
Umbilicus or
xiphoid to
medial
malleolus

RIGHT

LEFT

DIFFER
ENCE

88 cm

76 cm

12 cm

97 cm

98 cm

8 cm

Sig.: (+) TLL discrepancy 2 to bony deformity

(+) ALL discrepancy 2 to bony deformity
POSTURAL ASSESSMENT:
Findings: Pt. was assessed on a standing position on the anterior, posterior,
and lateral view with his cane to support his weight.
Anterior
Posterior
All landmarks were
All landmarks were
unleveled c R side
unleveled c R side
higher than the L
higher than the L
(+) L genu valgum
Lateral View
(+) anterior trunk lean
(-) Kyphosis
(-) Lordosis
(+) L Knee is hyperextended
(+) R Knee is bent
Sig: Compensatory posture 2 leg length discrepancy.
GAIT ASSESSMENT:
Findings:
Weight-bearing
Status
AD

Full weight bearing on R LE

Cane

Type of Gait
Deviation

3-pt. Gait
Pt. has no movement on his L LE but lifts and
swings hip upon midswing phase of R LE.
Independent
Pt. guards LLE to prevent it from swinging too
much.

Quality of Support
Others

Sig.: Gait deviations 2 to uneven leg lengths.

FUNCTIONAL ANALYSIS:
Self-care
Feeding:
7
Grooming: 7
Dressing:
6
Bathing:
7
Toileting:
7
Bed mobility
Roll to right: N/A
Roll to left: N/A
Supine to sit:
Sit to supine:
Transfers
Bed to chair: 6
Sit to stand: 4
W/c to toilet: N/A
Ambulation: 6

7
6
5

4
4

FIM LEVEL
Complete Independence
Modified Independence
Supervision
(100%)
Minimal Assistance
(75%)
Moderate Assistance

3
(50%)
2
Maximal Assistance
(25%)
1
Total Assistance

A:
PT Impression:
Procedural Intervention:
Rehabilitation Prognosis:
Problem List:
Problem List
1.
P:
PT Mx:
Suggested Mx:
Precaution:

PREPARED BY:

STG

LTG