INITIAL EVALUATION

General Information
Pt name: M.R
Age: 50 y/o
Sex: M
Address: Naguilian, L.U
Civil Statatus: Married
Handedness: R
Occupation: Tricycle driver
Religion: R.C
Referring Unit: In-patient
Referring MD: Dr. M
Rehab MD: Dr. T
Date Reference: October 21, 2016
Date IE: October 21, 2016
Dx: Gouty Arthritis

S:
c/c: Agsakitditoy sakak inggana ditoy tumeng ko, ken narigat ko nga igaraw
PT translation: Pt c/o of pain in his feet & knees, and has difficulty in
mobilization.
HPI:
Pt states that he is a regular alcohol beverage drinker & every p work he is used
in drinking alcohols (3 cans/day) at home. He is also used in buying street foods
as his dinner most specially the intestines of pig during his overtime. Pt also said
that he notice himself going often in rest room to urinate. Symptoms started last
night when he was going to sleep which he described as sudden pain felt on his
(B) LE c PS 10/10. The pain was too much that even the bed sheets would give
him so much pain so he took 1 tablet of colchicine (1.8 mg) that help dec. pain
into PS of 7/10. The next day, which is today, he immediately go to the hospital
to seek help.
The pt had the same attack last month that made him immobile for ~12 days c a
PS of 7/10 but when the pain stops he didnt bother going to hospital and just

continue working for his family. He only manage the pain by elevating his leg
using a pillow and flex his hips and knees portraying a hook-lying position.
PMHx: Pt has a hx of type 1 DM & uncontrolled HTN
FMHx
HTN
DM
Arthritis

Mother
+
+
-

Father
+
+

PSHx: Pt has an active lifestyle and lives in a bungalow house c his wife & son.
BR to CR: 5 steps, LR to DR: 6 steps, MD to BR: 10 steps. Pt is an active smoker
(10 sticks/ day) & a regular alcohol beverage drinker. Pt has no hx of abuse
substance.
Pt Goal: Kayat ko nga maikkat atoy sakit na ken agmaneho manen.

O:
VS:

BP: 130/90 mmHg

RR: 15 cpm
PR: 79 bpm
To: 37o
OI:
Alert/ Coherent/ Cooperative
Manner of arrival: Bed bound
Physique: Ectomorph
Gait Assessment: N/A
Postural Deviation: N/A
(+) Tophi (B) hams, (B) MTP, 1st digit
(-) Swelling
(-) Redness
(-) Atrophy
Palpation:
Normothermic on (B) knees & feet
Normotonic on all muscles

(+) grade 3 tenderness

(+) (m) spasm
(-) edema
ROM:
Motion
Hip Flexion
Hip
Extension
Knee
Flexion
Knee
Extension
Dorsiflexio
n
Plantar
flexion
Inversion
Eversion
MTP
Flexion
MTP
Extension
IP Flexion
IP
Extension

Norma
l
o
0
120o
120o
0o
0o
120o
120o
0o
0o 15o

(R)
AROM PROM
0o - 70o

0o 45o
0o 30o
0o 18o
0o 40o
40o - 0o
0o 60o
60o - 0o

Findings: LOM 2o to tophi

Sig:
MMT: N/A
Special Tests:
Neuro Examination:
Functional Assessment:

A:
PT Impression:
PT Intervention:

Endfe
el

(L)
AROM PROM

Endfe
el

Rehabilitation Potential:
Problem List
LOM
Pain

P:

STG

LTG