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PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle

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ICD-10-CM Code: M62.81 (Generalized muscle weakness), M25.562 (Pain in L knee),


M25.462 (Effusion in L knee)

Patient Name: Taylor Loftner DOB: 6/08/1942


Date of Service: 4/17/2018

BACKGROUND INFORMATION:
Referral Source: Pt. referred to PT by Dr. Jack Smith, an orthopedic surgeon.
Referring Diagnosis: L Total Knee Arthroplasty (TKA) secondary to OA.
Treatment Requested: Pt. referred to PT for evaluation and treatment.
Other Referral Information: Pt. has history of OA. Pt. underwent a L TKA after
imaging revealed tricompartmental arthritis with approximation of the medial femoral
condyle and tibial plateau. Imaging also showed a loss of joint space with a lateral shift
of the patella. Normal blood work following procedure. Relevant discharge findings from
acute care PT include:
AROM: -3° L knee extension, 65° L knee flexion.
PROM: -5° L knee extension, 70° L knee flexion.
Ambulation: FWW x 40 ft with pain.
Stairs: Moderate assist x1 with 2 railings x3 steps; pt. unsafe.
Balance: Bilat. UE support for static/dynamic balance and moderate assist x1.
DC Recommendation: Inpatient rehabilitation secondary to required assistance,
home set-up, and limited family support.

SUBJECTIVE:
Pt. is a 75 y/o Caucasian female who received a L TKA 3 days ago. Pt. spent 3
days in a local acute care hospital. Pt. sent to inpatient rehabilitation to increase stair
mobility, bed mobility, independent transfers, long distance ambulation, and to increase
overall pt. safety.
History of Current Complaint: Pt. c/o pain on the medial side of her L knee for
2 years. 6 months ago the pain became too severe and the pt. had to stop exercise and
volunteering. Pts. main complaint was pain with descending stairs and pain/swelling in L
knee. 3 months ago pt. consulted with her physician and proceeded with a L TKA
following evaluation of radiographic imaging. TKA was performed on 4/14/18 with
successful placement of component hardware with three prosthetic components. No
complications with surgery. Pt. is 3 days s/p L TKA and is “feeling better” with a current
pain of 5/10. Pain at best is a 4/10 and is decreased with rest and hydrocodone PRN. Pain
is increased with walking, weight-bearing, and when using LLE a lot; pain at worst is a
6/10. Pain is dull, achy, and primarily located directly over the anterior L knee.
Current Functional Status/Activity/Participation Level: Pt. has been up
walking 2 times a day. Pt. walks down the hallway and back with a lot of pain in her L
knee. Pt. states she needs moderate assist x1 with bed mobility, transfers, and ambulating
on stairs. Pt. only able to ambulate approximately 40 ft before needing therapeutic rest
secondary to pain.
PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle
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Prior Level of Function: Prior to sx. and onset of severe pain 6 months ago, pt.
golfed and exercised daily. Exercises included walking and light resistance for muscular
endurance. Pt. also volunteered 5 days a week at the local animal shelter by walking
dogs. Pt. was independent with all ADL’s.
Medical/Surgical History; General Health Status: Pt. in overall good health
but has hypertension and non-insulin-dependent diabetes mellitus. Pt. exercises regularly
to control diabetes. Pt. had a L knee arthroscopy 5 years ago and 20 years ago with no
complications.
Family Health History: No significant family health history.
Current Medications: Pt. is taking hydrocodone PRN (typically 1-2x day) for
pain. Pt. unsure of dosage.
Allergies: Pt. has no known allergies.
Employment Status/Work Environment: Pt. is a retired middle school teacher.
Pt. volunteers 5 days/week at local animal shelter and walks dogs approximately 1 mile.
Home Environment: Pt. lives in a tri-story home. Kitchen, living room, and
partial bathroom located on the main floor. Pts. master bedroom and bathroom are located
on the upper level. An additional bedroom, living room, and bathroom are located
downstairs. There are 10 steps to the upper level and 10 steps down to the basement; both
have railings on the the L going up and on the R going down. Also, there are 2 steps into
the garage and the front entrance of the home, both without handrails.
Social/Cultural History: Pt. does not drink or smoke. Pt. is a widow and lives
alone. Pt. has two grown children who are willing to help after discharge; however,
children live 1-2 hours away and have limited time available to take off work. Pt. does
not want to be “a burden” on her children and wants to be independent with ADLs. Pt.
also has several grandchildren who are active in sports. She enjoys being able to support
them and attend their competitions and events.
Patient Goals: Pt. wants to decrease pain and swelling in her L knee, increase
LLE muscular strength, ambulate without an assistive device, ascend/descend stairs
safely and without pain, return to daily activities (golfing, volunteering, and exercising)
without pain and/or limitations. Pt. wants to be independent with transfers, bed mobility,
and ADLs.

OBJECTIVE:
Systems Review:
Cardiovascular/Pulmonary: HR: 72bpm, BP: 112/72mmHg, RR: 18bpm, O2:
100%. All vitals were obtained while the pt. was sitting. HR, BP, and O2 were taken on
the R arm. Pt. did exhibit dizziness due to orthostatic hypotension when transferring from
supping to sit; pt. was monitored and returned to normal after a 2 minutes.
Integumentary: Pt. had moderate warmth and erythema on L knee. Significant
swelling is present in L knee. No other abnormalities were present.
Musculoskeletal: Pt. has an overall mesomorphic body type. Pt. is 5’9” and
weighs 165 lbs. No obvious muscular abnormalities are present. Pts. gross strength and
PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle
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AROM was WNL in bilat. UE. RLE gross strength and AROM is WNL. LLE AROM and
gross strength is diminished.
Neuromuscular: Pts. overall coordination and movement patterns were normal
and as expected. Pt. was unable to balance on L due to pain.
Communication/Affect/Cognition: Pt. was present, alert, and oriented
throughout the entire evaluation and treatment.

Examination:
General Anthropometric Observations/Posture:
Right (cm) Left (cm)
10cm Sup. to Base of Patella 50 54
Base of Patella 46.5 49
Center of Patella 45 48.5
Apex of Patella 44.5 47
Tibial Tuberosity 40 45.5
Inspection/Observation: Pt. has moderate redness and warmth around the
incision site. A 30cm incision runs vertically on anterior L knee. Pt. has 25 staples
holding the incision closed. Incision is healing well with small scabs surrounding the
incision line. No drainage or signs of infection are present.
Neurological/Sensory: Pt. has diminished sensation to light touch around the L
knee. Diminished sensation most likely secondary to increased swelling.
ROM: Gross bilat. screen of UE ROM was performed to asses ability to ambulate
with walker; no ROM limitations were present. RLE AROM and PROM were WNL.
LLE ROM was WNL except for the L knee. L knee AROM and PROM were diminished
compared to the R knee.

Right Left
Hip Flexion WNL WNL
Hip Extension WNL WNL
Hip Abduction WNL WNL
Hip Adduction WNL WNL
Knee Flexion WNL 62° AROM/70° PROM Painful end-feel
Knee Extension WNL 10° AROM/5° PROM Painful end-feel
Anke Plantarflexion WNL WNL
Ankle Dorsiflexion WNL WNL
PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle
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Ankle Inversion WNL WNL


Ankle Eversion WNL WNL
Muscle Length/Flexibility: Not assessed at this time.
Strength/MMT: Gross bilat. screen of UE strength was performed to asses ability
to ambulate with walker; no muscular limitations were present. Bilat. hip strength was
5/5. R knee strength was a 5/5. No resistive movements or motions were performed on L
knee as they are to be avoided at this time. L knee functional strength was assessed
during gait and sit-to-stand transfers. RLE strength was 5/5 throughout.
Palpation: Pt. has tenderness to palpation on and around the L knee. Pain is
increased to a 7/10 with gentle palpation of the L knee.
Joint Play Assessment: L patellofemoral joint mobilizations are limited in all
directions.
Special Tests: Not assessed at this time.
Gait: Pt. was ambulating with a standard walker and able to ambulate
approximately 50 ft. Pt. has limited knee flexion with slight L hip circumduction. Pt. has
deceased stance time and stride length and able to put weight <50% of body weight onto
her LLE. Pt. struggles with using the walker on the stairs and needs mod. assistance x1.
Functional Mobility: Pt. needs moderate assistance x1 with bed mobility
(scooting, rolling, sitting up), transfers (supine-to-sit, sit-to-stand, stand-to-sit), and
ascending/descending stairs.
Balance: Pt. unable to perform single leg balance on LLE due to pain.
Standardized Outcome Assessments: Pt. completed a Lysholm Knee Scoring
Scale and scored a 37/100 thus equaling a 63% disability. This scale indicates pt. has
significant limitations with daily functional activities.

INTERVENTIONS (must include consent to treat and patient participation in goal


setting): Pt. was informed that she presented with generalized LLE muscular weakness,
pain and swelling in L knee, and decreased AROM/PROM secondary to her TKA
procedure. Pt. was informed of all findings throughout the evaluation. Pt. provided
informed consent to treat throughout the entire plan of care with all of the following
interventions.
Pt. was educated about the warning signs of infection (bright red, warmth,
discharge, swollen, pain) and educated how to contact a health care provided if an
infection was suspected. The incision was inspected and evaluated with no current signs
of infection present.
Bed mobility, transfer training, and gait training were all performed. Pt. was
educated on proper technique and important safety precautions. Pt. then performed bed
mobility and sit-to-stand transfer with moderate assistance x1. Gait training on a flat
surface with a standard walker and a step-to PWB gait was performed. Pt. was able to
ambulate approximately 40 ft. with verbal cues before needing 2 minutes of therapeutic
rest. Pt. then ambulated 40 ft. back to her wheel chair. Pt. was then educated how to
ascend and descend stairs with a standard walker and a stair railing on the R going up and
PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle
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L going down, to mimic her stairs at home. Pt. was able to ascend and descend 5 stairs
with moderate assistance x1 and verbal cues on walker placement.
Pt. was provided with a HEP that includes therapeutic exercise to increase
muscular strength and endurance as well as increase ROM. Pt. was educated how to
perform ankle pumps, gluteal sets, hamstring sets, quad sets, heel slides, and supine SLR.
Pt. will perform 2 sets of each exercise 3 times a day for at least 10 repetitions each. Pt.
then performed each exercise with verbal cues on proper technique and optimal body
position. The pt. was informed to not place anything under her knee for support. Pt. was
educated to place a pillow under her lower leg and ankle; this would provide support to
her lower leg while also providing passive resistance from gravity to help increase knee
extension ROM. Pt. was educated that she could use ice to help alleviate pain and
swelling in her L knee. Pt. was educated that she could use ice for 20 minutes at a time
with a pillow case or blanket between her skin and the ice. Pt. educated that she needs to
monitor her skin for erythema and to remove the ice for at least an hour to allow adequate
blood volume to return to the affected area.

ASSESSMENT:
PROBLEMS:
Body Structure/Function Alterations:
1. Decreased L knee extension and flexion AROM/PROM
2. Pain in L knee never better than 4/10 and 6/10 at worst
3. Significant swelling in L knee
4. Generalized and functional LLE muscle weakness

Activity Limitations/Participation Restrictions:


1. Unable to fully weight bear on LLE
2. Unable to ambulate more than 40 ft secondary to pain
3. Altered gait pattern due to muscle weakness and decreased AROM
4. Moderate difficulty ascending and descending stairs without assistance

Summary-Clinical Impressions: Pt. has generalized LLE muscle weakness, pain,


swelling, and decreased L knee AROM/PROM secondary to TKA procedure. Pt.
responded well to treatment today and will greatly benefit from PT. Subacute PT for 2
weeks will allow the pt. to become more independent in functional activities such as
ambulating throughout her home as well as ascending and descending stairs safely.

PT Diagnosis: Pt. has decreased L knee AROM secondary to generalized LLE weakness.
Pt. has LLE weakness due to disuse following TKA procedure. Pt. has decreased L knee
PROM due to pain and swelling in knee. Pt. has pain and significant swelling in L knee
secondary to TKA procedure.

Rehab Potential/Prognosis: Pts. rehab potential and prognosis is good. Pt. is motivated
to return to functional activities independently as well as return to her favorite activities
PTH 633 SOAP Note Template THERAPIST NAME: Lyndsay Ruckle
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such as golfing and volunteering at the animal shelter. Pt. also has family who is willing
to help her immediately following discharge and make the transition back home safely.

GOALS:
Short-term (to be achieved in 1 weeks):
1. Pt. to decrease pain to at least a 4/10 at worst to allow pt. to increase weight
bearing to 75% to ambulate her home safely and independently.
2. Pt. will increase ROM by 5° for both knee flexion and extension to allow for a
functional gait to allow pt. to ambulate through home safely.

Long-term (to be achieved in 2 weeks):


1. Pt. to increase overall functional strength to allow her to perform bed mobility,
transfers, and ambulate on stairs independently and safely throughout her home.
2. Pt. will be able to perform HEP independently to allow for continued symptom
relief following discharge.

PLAN OF CARE: Pt. will be seen for PT treatment 5 days a week for 2 weeks.
Treatment will include bed mobility, transfer training, gait training, and stair training.
Treatment will also include therapeutic exercise for muscular strength and endurance as
well as increase overall ROM. Treatment could potentially include modalities such as e-
stim, ultrasound, and ice to assist with pain and inflammation. The pt. will also
participate in a daily HEP that includes therapeutic exercise. The pts. progress with be
evaluated daily and the plan of care will be altered as necessary.

______________________________ SPT

If requested for case:


Current Procedure Terminology Units Duration
(CPT) Billing Codes
97162 (Moderate Complexity 1 Unit 20 minutes
Evaluation)
97110 (Therapeutic Exercise) 1 Unit 15 minutes
97116 (Gait Training) 1 Unit 25 minutes

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