Knee Evaluation - Physical and Occupational Therapy ...



Knee EvaluationName___________________________ DX_________________________________________ Date_________________Current Meds______________________________________________________________________________________PMH_____________________________________________________________________________________________Physician_______________________________Next Appt___________________Onset_______________Initial Evaluation_____ Re-Evaluation_____ Pain Rating_________Funct. Rating__________Involved: R L SUBJECTIVE: Pain with _____squatting_____walking_____sitting_____running_____stairs____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C/c:_____________________________________________________________________________________________Occupation/Social Hx:_______________________________________________________________________________ Work Duties:______________________________________________________________________________________Pt. Goals:_________________________________________________________________________________________OBJECTIVE:Gait: _____antalgic Trendelenburg R L _____Crutches_____Walker_____Cane_____No AD _____FWB_____PWB_____TTWB_____NWB_____WBAT Other_______________________________________________________________________________________________________________________________________________________________________Observation: (In Standing)WNL R L Knee: Genu Valgum R L Genu Varum R L Genu Recurvatum R L Pat. Mobility/ Assessment:___________________________________________________________________________Effusion:R none min mod severe L none min mod severe Foot:Pes Cavus R L Pes Planus R L Hallux Valgus R L Other____________________________________________________________________________MMT strength:R LKnee ext _____ P _____ PKnee flex _____ P _____ PDF_____ P _____ PHip Flex _____ P _____ PHip Ext. _____ P _____ PHip ABD _____ P _____ PROM: Knee AROM: ____ - ____ - ____Quad Recruitment: ___________Knee PROM: ____ - ____ - ____Extension Lag: ______Palpation: ________________________________________________________________________________________Girth Measurements: (From mid-patella) WNL Bruising Temp. WNL Warm___ aboveR _____L_____Mid PatellaR _____L_____ ___ belowR _____L _____Name:_________________________________________ DOB:___________ Resting BP: ___ / ____ Resting HR: _____Neurological Screen:Sensation:Normal R LOther_____________________________________________________Reflexes:Quads R_____L_____ Achilles R_____L_____Flexibility:(NT= normal, T= tight, VT= very tight): ______________________________________________________________________________________________________________________________________________________Special Tests: (+ or )RLRLVarus test__________McMurray’s__________Valgus test__________Post Sag__________Lachman’s__________Steinman__________Apprehension__________Pat. Grind__________6” step test:RWNL painful weakness/ control Unable to perform LWNL painful weakness/ control Unable to perform Single leg squat:RWNL painful weakness/ control Unable to perform LWNL painful weakness/ control Unable to perform Treatment:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ASSESSMENT:_____See Initial Eval Summary/ Plan of Care____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rehabilitation Potential:Excellent Good Fair PoorSTG/LTG:_____ See Initial Eval Summary/ Plan of CarePLAN:(Circle) # Rx/ wk______~ # wks______ Therex Strengthening Stretching Endurance Moist Heat/ Cold Pack Bracing/ Taping Ultrasound EStim Iontophoresis ASTYM Home Program Gait Training Balance Activities Manual Therapy Gait Training Other:___________________________________________________________Avg. Pain Rating _____Self Reported Functional Rating _____Knee Outcome Survey: _____Therapist Signature:________________________________________ Date:____________ Time:___________ ................
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