CASE 2-20C

Physical Therapy Evaluation

Dr. Green decides that Terra would benefit from a physical therapy program based on the initial assessment performed by Dr. Barneswell. Dr. Barneswell conducts a complete re-evaluation prior to the beginning of Terra's therapy program.

LOCATION: Outpatient, Clinic

PATIENT: Terra Benson

REFERRING PHYSICIAN: Ronald Green, MD

PHYSICIAN: Mary Barneswell, MD

SUBJECTIVE: Terra was referred for direct physical therapy on a twice-weekly basis to increase lower-extremity range of motion, and strength, and to increase weight-bearing tolerance, and for assisted transfer training. Programming should include therapeutic pool, if available. Terra recently underwent multiple orthopedic procedures at the Manytown Children's Hospital, including femoral derotation osteotomy on the left, bilateral rectus femoris lengthening, phenol injection, and two left hip adductor tendons. She returned to see Dr. Almaz last Monday to have a recheck appointment, at which time all restrictions were lifted, including weight-bearing. Referral was written to begin physical therapy programming. Terra was accompanied today by her father, who lifted her from her manual wheelchair to the elevated mat for evaluation.

OBJECTIVE: Observation: Terra arrives seated in her manual wheelchair with her left hip in a position of internal rotation and adduction. Her right hip was in a neutral position. She stated that she has decreased endurance for lower-extremity weight bearing because her left hip begins to hurt after approximately 10 minutes of standing in her stander.

Lower-Extremity Passive Range of Motion:

JOINT RIGHT LEFT

Hip flexion 120 degrees 107 degrees

Hip abduction 25 degrees 16 degrees

Straight leg raising 90 degrees 85 degrees

Excessive dorsiflexion 20> 10 degrees

Lower Extremity Strength:

MUSCLE GROUP

Quadriceps F/F+ F

Hip abductors P P

Hip flexion F F

Hamstrings F P+

Hip extensors P P

Tone in the lower extremities is increased. Mobility: Terra requires maximum assistance for standing pivot transfer from wheelchair to elevated mat. She requires a moderate assist to roll over from supine to prone and minimal assistance to roll from prone to supine. Her main means of mobility is by way of her power wheelchair. Gross Motor Skills: Terra is dependent on her power wheelchair for mobility. Her mom and dad lift her from her wheelchair instead of allowing her to use transfer with moderate to maximum assistance. Terra stands in her stander, but is no longer able to walk. Adaptive Equipment: She uses her power wheelchair at school and has a stander for home use.

ASSESSMENT: Impression: Patient's legs are very deconditioned as a result of her recent surgery and recovery. All restrictions are lifted, and she is ready to take responsibility for her own transfers with assist as needed. Strengths: (1) Interacts well with others in her environment; (2) motivated and cooperative. Problem list: (1) Left hip resting position of internal rotation and adduction; (2) she is not actively involved in her own transfers; (3) leg spasms causing her sitting posture to be asymmetrical; (4) decreased hip abduction on left leg to migrate into windswept position to her right. Goals: (1) To improve sitting balance: Terra will sustain erect sitting posture with upper- and lower-extremity support while seated on the bench or elevated mat; (2) improved lower-extremity passive range of motion: increased left hip flexion to 120 degrees and left hip abduction to 25 degrees; (3) increased lower-extremity strength by a half to a full muscle grade; (4) improved sliding board transfers with standby assistance from wheelchair to elevated mat or bed or standing pivot transfer with minimal to moderate assistance.

PLAN/RECOMMENDATION: (1) Terra is ready to begin a program of direct physical therapy on a twice-weekly basis for 3 to 4 months. A portion of that programming will occur in the therapeutic pool. (2) Plan of treatment for physical therapy program is listed under goals. (3) Patient will be seen in the gym during 1 session in the week and in the therapeutic pool for the other sessions to maximize her outcome. (4) Terra should place a towel roll between her knees when sitting in her wheelchair (to keep her hips in neutral alignment) to reduce her hip muscle spasms in her adductor muscle on the left. This will also promote body symmetry. (5) Her home exercise program should begin with standing in the stander on a daily basis for 10 to 30 minutes. She tolerated a 1-minute stand today and should increase her tolerance for standing gradually up to 30 minutes. Her home exercise program will be updated as needed. (6) Terra will return to the office for a recheck appointment in 4 months' time.

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________