NATIONAL KIDNEYAND TRANSPLANT INSTITUTE

Initial Physical Therapy Notes

October 2, 2017
Name:
Age:
Sex:
Medical Dx:
S: c/c
Pt. Goal:
O:
VS
NORMAL BEFORE DURING AFTER
BP 120/80 mmHg
RR 12-20 cpm
PR 60-90bpm
O2 Saturation 98-100%
Temperature Afebrile to touch
Findings: VS are WNL
Significance: For precautionary measures and to assess if patient is eligible for therapeutic management.
OI
 Bedbound
 Ectomorph
Palpation
ROM: All joints of (R) LE were actively and passively assessed and were found to be WNL and pain-free except for the ff:
Differences
Motion (N) Value AROM PROM End Feel
AROM PROM

Findings:
Significance:
MMT: All mm groups of UE/LE, HNT were grossly assessed & graded 5/5 & was found to be WNL except for the ff:
Muscle Group Scale

Findings:
Significance:
Sensory Testing:
Anthropometric Measurement:
Postural Analysis:
A) Anterior View
Body Segment Normal Result
Eyes Eyes are level Eyes are level
Acromion Acromion are level (B) acromion are level
B) Posterior View
Body Segment Normal Result
Earlobe Earlobe are level Earlobe are level
Acromion Acromion are level (B) acromion are level
 Inferior Angle of Scapula are (B) Inferior Angle of Scapula are
Inferior Angle of Scapula
level level
C) Lateral View
Body Segment Normal Result
Earlobe is in line with the tip of Earlobe is in line with the tip of
Head
the shoulder the shoulder
Neck Neck in slight lordosis Neck in slight lordosis
Shoulders are in proper Shoulders are in proper
Shoulder
alignment alignment
Trunk Trunk in slight kyphosis Trunk in slight kyphosis
Significance: Normal Posture
Gait Assessment:
ADL Analysis:
A
PT Impression
Rehab Potential
Problem List
P
LTG: To be achieved within 2 mo of regular session; pt will be able to
STG: To be achieved within 1 mo of regular session; pt. will be abe to
POC: Pt will be seen as an IP, 10x a week daily & will receive the ff treatment:

PTRP Alejandro E. Ruiz III

PT staff in charge FEU NRMF PT Intern 2018