Initial Evaluation

07/15/19
Demographic Data
Name: R.R
Age: 51 y.o
DOB: 10/8/1968
Gender: Male
Address: GSIS Heights Matina Davao City
Handedness: R
Contact #: 09473033351
Religion: Roman Catholic
Race: Asian
Ethnicity: Davaoeno
Language: English, Tagalog, Cebuano
Referring MD: Dr. Bing Patricio, MD
Rehab MD: Dr. Gilbert Cauilan, MD
Date of eval.: 07/15/19
Dx: Pt. is dx c L comminuted radial head fc.
S:
C/C: Pt. c/o of difficulty playing lawn tennis due to inability to move L elbow, wwrist et hand on
all motions c stated deep nagging pain c PS 8/10 (0 = no pain, 5 = mod pain, 10 = severe pain).
HPI: Present condition started last 6/4/19 while playing lawn tennis as he is about to do a
backhand swing et. suddenly fell down c L elbow bent. Was partially unconscious et. his friends
brought him stat to Adventist Hospital under a physician unrecalled; Physician ordered x-ray on
same day et. finding was L radial head fx; told Pt. he needs to undergo surgery. Pt. was given
sling et. cast; went home; next day, Dr. Bing Patricio of Samal Hospital et. a friend of his
suggested he consults Dr. Cauilan about this at Davao Medical School Foundation (DMSF)
Hospital. Pt. took heed et. went to DMSF on 6/5/19. Attended by Dr. Cauilan, ordered x-ray,
FBS, ECG et. lung examination c findings of L comminuted radial head fx et. normal findings c
the rest, respectively. Pt. was admitted on same day; was a candidate for surgery et. had it on
6/6/19. Bone extraction was performed et. 4 fragments were placed on the bone. Pt. was given
2 tablets for pain p surgery, unrecalled meds. Was discharged a day p. held L UE immobilized
on a sling et. cast for 3 wks. On 7/1/19, went to Mindanao Orthopedic Sports et. Rehab Center
(MOSARC), consulted Dr. Madayag, was given unrecalled meds to take et. was ordered to
undergo PT Rx for further evaluation.
Prior Level of Function: Pt. was indep in doing self-care such as grooming, bathing, dressing
UEs et LEs; reaching things overhead; lifting heavy objects at home when taking out the trash
et. helping parents do house chores; does lawn tennis playing especially c double-fisted
backhand.
Functional Status: Pt. is still indep but has difficulty in doing self-care such as grooming,
bathing, dressing UEs et LEs; reaching things overhead; lifting heavy objects at home when
taking out the trash et. helping parents do house chores. Is unable to play lawn tennis especially
c double-fisted backhand.
Employment Status: Pt. is retired.
Social Hx: Pt. lives c his parents. Does not ask for help in doing his ADLs from parents. Parents
don’t give much help to him. Pt.’s friends on-court gives him emotional support. Is financially
stable.
Family Health Hx:
F M Pt.
DM (+) (+) (-)
 Arthritis (+) (+) (-)
HTN (+) (-) (-)
Heart (+) (-) (-)
disease
Respiratory (-) (-) (-)
disease
Medical/Surgical Hx: Date unrecalled, R radial et. ulnar fx, San Pedro Hospital (SPH), resolved;
Date unrecalled, cystectomy, SPH, resolved
Other Clinical Tests: X-ray c L radial head fx finding, physician unrecalled, 6/4/19; x-ray c L
comminuted radial head fx finding, Dr. Cauilan, DMSF, 6/5/19; FBS, ECG et. lung examination c
normal findings, Dr. Cauilan, DMSF, 6/5/19
Meds.: 2 unrecalled tablets taken p surgical operation, for pain, 6/7/19, Dr. Cauilan; Unrecalled
meds c unrecalled purpose taken p removal of cast, Dr. Cauilan 7/1/19; Calcium c Vit. D, bid,
500 mg, Dr. Cauilan; Vitamin C, 1000 mg, od, physician unrecalled.
Living Environment: Pt. lives in a 2-storey house c overhead cabinets located at his kitchen,
living room et bedroom. Has clotheslines outside of house.
Social Health Habit: = (+) alcohol beverage drinker, 2 bottles occasionally; (-) smoker; (+)
physical activity
General Health Status: Pt. rates his overall health 8/10 (0=poor, 5=average, 10=excellent) as he
has no other underlying conditions present.
Pt.’s Goal: Pt. states he wants to go back playing lawn tennis.
O:
Systems Review
Cardiopulmonary System
BP = 130/90 mmHg, R brachial site, sitting
PR = 70 bpm, R radial pulse, sitting
HR = 74 bpm, 5th L ICS, sitting
RR = 15 cpm, thoracic breather, sitting
Temperature = 37° C, R axilla, sitting
Integumentary System: Impaired due to shiny skin peeling, skin discoloration on L forearm et.
hand
Musculoskeletal System: Impaired
Gross Symmetry: Impaired L elbow flex contracture, atrophy on L biceps, triceps, et. forearm
muscles, pitting edema on L forearm, forward head, round shoulders, pelvic tilted posteriorly et.
kyphotic posture.
Gross ROM: Impaired on L elbow flex et. ext., forearm pronation et. supination, wrist flex et. ext,
radial et. ulnar deviations due to muscle et. joint stiffness.
Gross MMT: Impaired on L elbow due to muscle atrophy, muscle weakness et immobilization.
Wt.: 63 kg
Ht.: 5’5
BMI: 23.2 kg/m2, normal BMI
Neuromuscular System
Gait: Impaired due to dec stride et. step lengths, dec heel strike et. B hip et. knee flexed on all
phases of gait; dec BOS.
Locomotion: Unimpaired
Motor function: Unimpaired
Balance: Unimpaired
Communication Style: Unimpaired et. age-appropriate
Affect: Unimpaired emotional et. behavioral responses
Cognition: Oriented x 3 (time, place, person)
Learning Barriers: None
Learning Style: Pt. learns best c verbal cueing et. visual demonstration
Educational Needs: HEP, proper trunk, UE et. LE movements, postural education, proper body
mechanics
Test et. Measures
Ocular Inspection: indep. amb
mesomorph
(+) kyphotic posture
(+) forward head
(+) shiny skin peeling on L forearm et. hand
(+) skin discoloration on L forearm et. hand
(+) atrophy on L biceps, triceps et. forearm muscles
(+) L elbow flex contracture
(+) scar 2 ½ in on L elbow joint
(-) open wounds on L UE
(-) sling/cast on L UE
Palpation:
(+) pitting edema on L forearm
(+) muscle spasm on L forearm muscles, B supraspinatus et. pecs major
(-) tenderness on L UE
ROM: All major joints of B UEs/LEs were grossly assessed actively/passively done WNL et.
pain-free except:
AROM PROM N° Difference End feel
AROM PROM
L shoulder 0-80° 0-116° 0-180° 100° 64° Empty
abduction
L elbow flex 85°-88° 85°-88° 0 -150° 147° 147° Empty
L elbow ext. 85°-84° 85°-84° 150°-0 149° 149° Empty
L forearm 0-66° 0-68° 0-80° 14° 12° Empty
supination
L forearm 0-28° 0-30° 0-80° 52° 50° Empty
pronation
L wrist flex 0-60° 0-62° 0-80° 20° 18° Empty
L wrist ext 0-58° 0-62° 0-70° 12° 8° Empty
L radial 0-16° 0-18° 0-20° 4° 2° Empty
deviation
L ulnar 0-20° 0-24° 0-30° 10° 6° Empty
deviation
Sig: Pt. has LOM on L shoulder abd, elbw flex et. ext, forearm supination et. pronation, wrist flex
et. ext, radial et. ulnar deviation due to pain, muscle guarding et. muscle et. joint stiffness/
MMT: All muscles of B UEs/LEs are graded 5/5 except:
L shoulder abductors = 2+/5
L elbow flexors = 1+/5
L elbow extensors = 1+/5
L forearm supinators = 2+/5
L forearm pronators = 2+/5
L wrist flexors = 3-/5
L wrist extensors = 3-/5
L radial deviators = 3-/5
L ulnar deviators = 3-/5
Sig: Pt. has dec muscle strength on these muscle groups due to immobilization et. dec physical
activity.
Legend:
GRADE MOVEMENT GRADE
5 Full ROM, against gravity, w/ max resistance
4+ Full ROM, against gravity, nearly max resistance
4 Full ROM, against gravity, w/ mod resistance
4- Full ROM, against gravity, nearly mod resistance
3+ Full ROM, against gravity, min resistance
3 Full ROM, against gravity
3- 50% but not full ROM, against gravity
2+ Full ROM, gravity minimized, min resistance
2 Full ROM, gravity minimized, (-) resistance
2- 50% but not full ROM, gravity minimized, (-) resistance
1+ <50% ROM, gravity minimized, (-) resistance
1 Palpable contraction, (-) joint movement
0 (-) palpable contraction
LGM: Affected area: L
L R Difference
L forearm 23 cm 21 cm 2 cm
Sig: Pt. has pitting edema on L forearm due to immobilization of L UE.
MBM: Affected area:
L R Difference
L biceps et. triceps 22 cm 25 cm 3 cm
L forearm muscles 19 cm 21 cm 2 cm
Sig: Pt. has atrophied L biceps, triceps et. forearm muscles due to disuse.
Postural Analysis: Standing
AP Lat
Head Midline Forward head
Neck Midline Flexed
Shoulder Symmetrical Protracted scapula
Elbow Symmetrical L elbow flex contracture
Wrist Symmetrical Brought by L elbow flex
contracture
Trunk Midline Kyphotic
Pelvis Midline Post. Pelvic tilt
Hip Symmetrical Flexed
Knee Symmetrical Flexed
Ankle Symmetrical Midline
Sig: Pt. has postural deviations: forward head, protracted scapulas, L elbow flex contracture,
kyphotic posture et. post pelvic tilt due to physiologic changes as one ages, muscle et. joint
stiffness.
Gait assessment:
a. Dec step et. stride lengths
b. dec heel strike
c. B hip et. knee flexed on all phases of gait
Sig: Pt. has gait deviations due to physiological changes on aging, dec physical activity et.
muscle weakness.
Special Test
(-) Piano Keys test = (-) distal radioulnar joint instability
(-) Murphy’s Sign = (-) lunate dislocation
(-) Biceps Squeeze test = (-) biceps tendon rupture
Sig: Pt. has no other medical conditions aside from L radial head fx.
Assessment Tools
Oxford Elbow Scale
Sig: Pt. reports mod difficulty in lifting, self-care et. max difficulty in dressing; has totally
interfered c usual work or everyday activities; limited his ability to take part in leisure activities
that he enjoys.
FIM: Score of 6.7
Sig: Pt. is modified indep due to difficulty in eating, grooming, bathing et. dressing.
DASH: Disability score of 54.2%
Sports/Performing arts score of 100%
Sig: Pt. has these scores especially on sports due to muscle et. joint stiffness et. LOM that L
elbow flex contracture gives.
UEFS score of 22/80
Sig: Pt. has difficulty c his usual hobbies sporting et. household activities, in lifting heavy objects
c washing clothes, throwing et. self-care due to to LOM et. muscle strength of L shoulder,
elbow, wrist et hand c their muscle groups.
A:
PT Dx: Pt. has difficulty in lifting heavy objects, overhead reaching, household chores, gripping
et. grasping objects due to LOM on L shoulder elbow, wrist et. hand on all motions, sig dec
muscle strength on L shoulder elbow, wrist et. hand muscle groups, et perceived deep, nagging
pain of 8/10 on elbow, which makes him unable to play lawn tennis.
Pt. Prognosis: Pt. has fair rehab potential in terms of playing lawn tennis as he has no other
medical conditions present aside form L radial head fx; has intact sensation; et. is modified
indep according to his FIM score; however has LOM, pain, et dec muscle strength; has sig
disability et. sports performing scores of 54.2% et. 100% et. UEFS score of 22/80 which
indicated him to be restricted to et. has difficulty in doing ADLs et. recreational sports et.
activities; this might delay or hinder rehab potential.
Problem List:
Impairment
1. Pt. has deep nagging pain c PS of 8/10 (0=no pain, 5=mod pain, 10=severe pain) on L elbow.
2. Pt. has LOM on L shoulder abduction, elbow flex et. ext, forearm pronation et. supination,
wrist flex et. ext radial et. ulnar deviations.
3. Pt. has dec muscle strength on L shoulder abductors, elbow flexors et. extensors, wrist
flexors et. extensors, forearm pronators et. supinators, et. finger flexors et. extensors.
4. Pt. has pitting edema on L forearm c difference of 2 cm.
Activity Limitations
1. Pt. has difficulty c reaching overhead.
2. Pt. has difficulty lifting heavy objects.
3. Pt. has difficulty gripping et. grasping objects.
4. Pt. has difficulty in doing self-care.
Participation Restriction
1. Pt. is unable to play lawn tennis.
Goals
-------
P
PT Treatment
1. TECAR therapy on L elbow joint x 10 mins
2. AAROM c GPS of elbow, wrist, forearm et. hand x 10 sh x 3 reps
3. Strengthening of L biceps et. triceps, pronators et. supinators, et. wrist flexors et. extensors
using manual resist. X 10 sh x 5 reps
4. HEP
Suggested PT Treatment
1. AAROM c GPS on L shoulder on all motions x 10 sh x 5 reps
2. Grip strengthening using squeeze ball et. power grip x 10 sh x 5 reps
3. Joint mobilization on L shoulder x 2-3 oscillations/sec x 3 reps
a. Inf glide
b. Post glide
4. Joint mobilization on L wwrist x 2-3 oscillations/sec x 3 reps
a. Dorsal glide
b. Palmar glide
5. B Pecs major stretching x 10 sh x 5 reps
6. MFR B supraspinatus et. pecs major x 5 mins
In Progression
1. Strengthening of L biceps et. triceps, wrist flexors et extensors, forearm pronators et.
supinators et. finger flexors et. extensors using progressive weights et. theraband x 10 reps x 3
sets

Janelle Charisse Velez

DDC PT Intern