Patient With Knee Pain Essay

1327 words - 5 pages

Mrs Jones is a 65 year old white female patient, who medical history is unremarkable and current medical diagnosis is Joint Pain –L/Leg LOC PRIM Osteoart-L/Leg. Patient has experience pain to left knee about one years ago, received injection to left knee but did not help with pain , pain became worse. Mrs. Jones under went her 1st surgery 09/17/2013 Mrs. Jones was in a hospital for four days and took part in home health physical therapy for two weeks but experienced no improvement. Initial physical therapy diagnosis is TKR. Mrs. Jones visited Selected physical therapy on Oct 17, 2013, chief complain of pain current severity 5/10, severity at worst 8/10 pt feel restricts in activity like walking, sitting, squat and not been able to take care of her grand daughter, location of pain knee anterior , duration intermittent , pain nature stiff and aching. The PT did a functional test balance on Mrs. Jones which was poor, gait/locomotion perform to left knee WB status was full weigth bearing, assistive device rooling walker, cadence was moderate decrease and swing phase was also decrease.
Muscle testing to lower extremity MMT. Hip Flexion Left 2/5 Right +4/5,Knee Extension left 2/5, right 5/5, Knee Flexion left 3/5 right 5/5. Range of motion extension left AROM +15, left PROM none, Flexion left AROM 62, left PROM 66, Extension AROM 0, Flexion AROM 124. Pt present with moderate weakness and stiffness in her left knee after a TKR, Mrs. Jones would benefit from therapy 3 times a week to aid with improving her functional activities and aiding her to become independent with ADL’s, skilled intervention required to decrease pain, improve function, increase range of motion and increase strength, treatment emphasis to focus on pain relief, range of motion/mobility improvement , proprioception/balance improvement , muscle function improvement and maximizing function related to ADL’s activities. Problems and Goal, problem 1 functional Capability, Pt lives with her brother in an apartment on the second floor , she states she is able to climb up and down stairs but does so slowly and perform one step at a time . she is not able to drive secondary to not being able lift her left knee.
PT STG Achieve by Nov 07,2013 functional Improvements , pt will be able to drive herself to and from Dr. visit and therapy visits. Problem 2. chief complain severity at worst 8/10. PT LTG Achieve by Nov 14, 2013. symptomatic improvements to decrease pain to 4/10. Problem 3. functional capability working status. Pt cleans apartment for a living and states she needs to be able to walk/stand for up to 6 hours, squat and climb step stools in order to return to work. PT LTG Achieve by Dec 16, 2013, functional improvements work capacity, returning to full time or unstricted duty. Problem 4. Muscle testing lower extremity MMT STG Achieve by Nov 07,2013. Hip abduction left 3/5, hip flexion 3+/5, knee extension 3+/5 , knee flexion 3+/5 , hip extension 3/5 and ankle PF 3+/5...

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