Case 1 
Physical Therapist Assessment

ROM – 

            Hip flexion 110 bilaterally

            Hip extension - neutral

Knee flexion 90 bilaterally

Knee extension –10 bilaterally

            Ankle dorsiflexion to neutral bilaterally

            Shoulder-140 R, 120 L

            Elbow WNL

            Hands WFL, some arthritic changes in fingers

Posture (standing)– forward head with slight increase thoracic kyphosis

Pelvic obliquity due to leg length discrepancy

Strength – LE strength generally 4/5

Sensation – Patient wears thick glasses at all times.

Decrease light tough and pinprick sensation on Bilateral LE, R>L.

Functional mobility

Gait - Patient ambulates with a walker, is able to take some steps without it holding onto surrounding furniture. He tends to walk fast with the walker. (slide 15, slideshow)

Sit-stand – able to perform Independently using upper extremities.  He has several pillows in his chairs to make this easier.

Supine to sit – patient is unable to accomplish this without assistance.  He has a strap attached to the wall near bed to help pull himself up. (slide 13, slideshow)

Stairs – patient requires a rail and hand held assist for flight of stairs.  Able to negotiate 1-2 steps to get in and out of house.

Car transfers – patient is able to get in and out of car independently

Endurance – Patient becomes SOB walking 20 feet with walker.  He is able to walk to mailbox and back (100ft).

Tinetti   18/28 (with walker)

Berg     25/56

Get-up and go-30 sec with walker

Assessment – Patient has some range limitations and decrease strength in the LE accompanied by sensory losses, which impact his ability to maintain upright balance.  He is functional in his home environment with adaptations that he has made (strap, pillows).  However he is at significant risk for falls by all three functional tools.  In addition he has poor endurance for functional activities.