Professional Documents
Culture Documents
June 5, 2017
Subjective> F.P. is a 52 y/o (-) HTN, (-) DM, (-) Asthma __ handed male was referred
for PT evaluation and management 2 to c/o constant localized uncomfortable deep
pain on (R) ankle, graded 2/10 on a subjective pain scale (0= no pain, 10= worst
possible pain), aggravated by prolonged position ~ __ mins., 1 st step in the morning,
fatigue to up to PS 4/10 and is relieved by walking and doing ankle movements
down to PS 2/10. HPI: Present condition started last May 12, 20117, when pt.
suddenly stumbled upon a sidewalk while crossing the street. Pt. said that hi foot
faced inward and his weight was all shifted to that area as he felt extreme pain PS
10/10 on (R) ankle. He continued his day as he got to work but went home early and
just slept the pain away. The next day, pt. felt extreme pain PS 10/10 as he stepped
his (R) leg first thing in the morning, this prompted him to go to the doctor by
afternoon on the same day. Pt. went to Commonwealth Hospital and was checked by
Dr. Heradura, he was asked to undergo X-ray (See ancillary procedures) and was
diagnosed c (R) ankle sprain on the same day and was then referred to PT
department of same hospital. Pt. had his first PT session by May 17, 2017 and only
continued up to his 4th session which included: HMP c TENS, PREs on (R) ankle and
LE bike ergometer. Pt.s friend recommended to have pt. checked at PHC which pt.
did and had a consultation c Dr. Agbayani last June 3, 2017. Pt. was then referred to
PHC-PMRD to undergo physical therapy. At present, pt. is ambulatory and c/o
tolerable but uncomfortable pain on (R) ankle and will be receiving PT 2x/week.
PMHx: Pt. had previous hospitalizations d/t vehicular accident 30 years ago, had
metal implantation on his (R) leg (tibia), underwent lymph node surgery a~ 20
years and had upper respiratory infection (B) ~ 20 years ago. Pt. denies having any
cardiac disease. Lifestyle and Work Situation: Pt. is a non-smoker and
alcoholic beverage drinker ~ 2 bottles a month. Pt. works in a government agency,
which requires him to do paper and computer works ~ 8 hours a day and 5x a week.
Home and Environmental Situation: Pt. lives in a bungalow type of house c his
wife, 2 kids, and mother who assists him in doing some of his ADLs. Pt. usually
drives to work for ~ 80 mins a day. Goal:
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MMT> All major mm. groups of (B) UE and LE were grossly graded 5/5 except:
(R) ankle dorsiflexors = 4/5; (R) ankle plantarflexors = 4/5