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Date of Referral Date of Onset Treatment Diagnosis

27JAN2018 26DEC2017 (L) ACL/MCL tear with surgical fixation


Physical Therapy Orders Intensive Rehab for (L) ACL/MCL
History of Present Illness
Inversion Ankle Sprain (R) 2008

Past Medical History


Pilonidal Cyst 2012 (surgical)

Precautions none

Prior Functional Level 100% powerlifting, full participation in field and PT events

Present Functional Level self-evaluation: 60-75% || initial subjective: 40-55%


Psychosocial History none
Allergies none Medications none
Range of Motion/Strength Orientation Responsiveness
ROM Strength Name: Bradley Austin Quinter Alert
ROM/Strength Left Right Left Right Hometown: Washington DC Lethargic
Upper Extremities Education: WVU for 1 year Responds to Verbal Cue
+ -2 + 1 Languages: English, French Responds to Demonstration
Hand + + + + Sports: Hockey, Football, Swimming Non-Compliant
Hobbies: Guitar, Fishing, Traveling,
Wrist + + + + Nintendo games Prior Ambulation

Forearm + + + + Community
Household
Elbow + - + -/ Follows Commands
Assist
Up. Arm + + + + Easily Distracted Device CR
Shoulder + - + /- Home Environment Non-Ambulatory
+ Align Neck + + Single Safety Awareness
Married (w/kids)
= Align Lats + + + + Poor
1 boy 5yrs – plays baseball
Lower Extremities -2 7- 2-- + 1 girl 3 yrs – tea parties, dress up, dogs
Fair
+ + Single Parent Good
- Align Lumbar Divorced Needs Verbal/Tactile Cues
Committed Relationship
= Align Hip + + + + Sensation
Thigh + + /- + No apparent nerve damage Pain Status
Groin + + + + Says pain is minimal but while performing
functional tests it is clearly visible that
Knee - + - + pain is present. Occasionally
L.Leg - + -/ + overcompensates with R Leg.
Ankle + /- + + Trunk Strength/ROM Psychosocial
Foot + + + + Poor Work on creating safe environment where
open dialog about pain and recovery are
Tone Fair
encouraged. Mentally tough but needs to
Outstanding physical fitness Good return to full participation when he is
Continue with core exercises to maintain physically healed .
Undercompensating L physique and mobilization
Coordination Barriers in Learning Endurance
Hand/Eye + Military training Extremely high pain tolerance compared to
past clients with torn ACLs. Will be able to
High pain tolerance
push patient during treatment plan but he
has been trained to not show emotion.
Comments PATIENT IDENTIFICATION
Lack Major Biomechanical issues
Adjustments made on Neck & Lumbar
Intensive Rehab of the L Knee Bradley Austin Quinter, PFC
Rehabilitation Therapy
Physical Therapy Evaluation
NT = Not Tested CGA = Contact Guard Assist WBAT = Weight Bear as tolerated Equipment HW = Hemiwalker
NA = Not Applicable Min. A = Minimal Assist PWB = Partial Weight Bearing CR = Crutches SW = Standard Walker
Codes

I = Independent Mod. A = Moderate Assist TTWB = Toe Touch Wt. Bearing SPC = Single Point Cane FWW = Front Wheel Walker
S = Supervised Max. A = Maximum Assist NWB = Non-Weight Bearing NBQC = Narrow Base Quad Cane 4WW = Four Wheel Walker
SBA = Stand By Assist U = Unable WBQC= Wide Base Quad Cane WC = Wheelchair
Functional Status
Mobility Assist Mobility Assist Mobility Assist Transfers Assist
Cut Right Max. A Lunge R Leg Mod. A Hop L Leg U Lateral WBAT
Cut Left Max. A Lunge L Leg U Hop R Leg I Forward Max. A
Stationary Squat PWB Jump TTWB Kneel-Stand CGA Backward Max. A
Balance Sitting Standing Gait
Static + Equipment n/a Distance (Feet) 3.0
Dynamic + Assist CGA Weight Bearing R/L
Gait Analysis
Slightly longer length of stay in swing phase

Assessment
Problems Plan of Treatment
Decline in Mobility Most mobility ex. need assist Mobility Training
Decline in Transfers All transfers need assist Transfer Training
Decline in Gait Favoring R leg Progressive Gait/Stairs Training
Safety Awareness Deficits Instructions on Safety
Balance Deficits Left leg Balance Training
ROM/Strength Deficits Overall loss of strength/ROM after Therapeutic Exercises (specify) Weekly plans to follow
surgery

Other (specify)
Other (specify)

Short Term Goals Long Term Goals


Improve Mobility to: 50% of normal function Improve Mobility to: 90% pre-injury
Improve Transfers to: 50% of normal function Improve Transfers to: 90% pre-injury
Improve Gait/Stairs Mgt. to: =1m/s Improve Gait/Stairs Mgt. to: >1 m/s
Improve Safety Awareness to: Improve Safety Awareness to:
Improve ROM/Strength to: 50% of normal function Improve ROM/Strength to: 90% pre-injury
Others (specify) Other (specify)
Coach son’s baseball team Pass medical board for deployment in 6 mo
Help around the house Be in good condition to go to Ranger School
Independent at Home Exercise Program Integration into unit training

My Goals: Integrate personal interests into training


At home rehab plan
Less than 180 days
Rehab Potential : 90-95% pre-injury ability Tentative Plans: Home Rehab Unit

Frequency/Duration of Treatment:2/wk for first 5 weeks || 1-2/wk for months 2-6 depending on improvement
Comments: Surgery performed well, no infection, outstanding PATIENT IDENTIFICATION
physical fitness should enable for a more rapid recovery

Registered Physical Therapist Date


Kira N. Donnelly 27JAN2018
Physician Approval Date
Bradley Austin Quinter, PFC
Leah Triolo 27JAN2018