INITIAL EVALUATION

GENERAL INFORMATION:
Pt Name
: B.P
Age
:46 y.o.
Sex
:F
Address
: Acao, Bauang La Union
Civil Status
: Single
Handedness
:R
Occupation
: None
Religion
: R.C.
Attending Doctor : Dr. C.G
Date of IE
: Nov. 25, 2016
Diagnosis
: Bilateral lymphodynamic edema, type II DM
S:
c/c: Mabigat yung legs ko na namamanhid tapos dito sa talampakan ko para
siyang tinutusok tusok
PT Translation: Pt. c/o heaviness & numbness on her (B) LE c pins and needle
sensation on the sole of her feet.
HPI: Present condition started 10 mos ago PTIE when pt. experienced blurred
vision & immediately went to her Ophthalmologist, however, an unusual optical
problem was seen. Pt. was then advised to undergo CBC & FBC which revealed high
glucose level & was referred to Dr. C.G. Pt. was then diagnosed of having Type II DM
& was prescribed to take medications however s regular check-ups.
3 mos PTIE, Pt. experienced SOB when doing strenuous activities & felt heaviness
and numbness on her (B) LE c pins & needle sensation on the sole of her fee.
Reoccurrence of symptoms, then again prompt the pt. to seek for medical advice.
Pt. was then informed that her condition worsened and have already affect her
kidneys and heart.
At present, pt. c/o heaviness & numbness on her (B) LE c pins & needle sensation on
the sole of her foot. Pts condition is aggravated when walking & when in prolonged
sitting or @ rest, pt. ask her niece to massage her LE however no relieving effect
was noted.
Pts condition irritates the pt causing min difficulty on doing ADL such as doing
household chores & mod. difficulty on ambulating & doing stair negotiation.
Ancillary Procedure:
ECG
(+) Tachycardia
02/09/16
HTC
unrecalled
02/09/16
CBG
Unrecalled
02/09/16
Peripheral smear
Unrecalled
06/07/16
blood morphology

unrecalled

06/07/16

PMHx: (+) HTN, (+) Diabetic Neuropathy, (+) Diabetic Nephropathy, (+) Diabetic
Retinopathy, (+) Eye Laser & Injection, (+) Heart Tachychardia (+) Hospitalization:
February 9, 2016, August 7, 2016, October 19, 2016
MEDICINE
DOSAGE
INDICATION
Normetec 20mg
1 tab 2x /day
For HTN
Nebilet 5mg
tab 2x /day
For HTN
Diumidek
1 tab every morning
For Edema

Tresiba inject
Galvus 50mg
Lipitor 80mg
Lyrica/Funxion 75mg

8 units daily
1 tab @ bedtime
tablet @ bedtime
@ bedtime

DM
DM
cholesteros
For neuropathy

FMHx:
PATHOLOGY
HTN
DM
Heart Dse.
Asthma

FATHER
(+)
(+)
(+)
(+)

MOTHER
(-)
(+)
(-)
(+)

PSHx: Pt. has a sedentary lifestyle c no hx of substance abuse, a non-smoker & a

non-alcohol drinker. Pt. is doing all of the household chores however d/t her present
condition she was advised to lessen physical exertion.
House Dimension:
Stairs = 10 steps (10 in height of stairs); bedroom bathroom ~8m; bedroom
dining area ~10m; bedroom main door ~10m
Note: Pt. is situated on the 2nd floor
Goal: Na sana pumayat na yung legs ko para hindi na ako nahihirapan maglakad
O:
VS:
BP:
PR:
RR:
To:

130/80 mmHg
81 bpm
22 cpm
36.9 C

OI:
Manner of Arrival: Ambulatory s AD
Mental status: A/C/C
Physique: Mesomorph
(+) Scaling
(+) Dry skin
(+) Gait Deviation
(-) Postural Deviation
(-) Gangrene
(-) Ulceration
Palpation:
Thermal Assessment: Normothermic in all exposed body parts, head & neck
except hypothermia on (B) Legs & feet
Tone Assessment: Normotonic in all exposed body parts
(+) Tenderness (B) LE
(+) Non-pitting Edema on (B) LE
(+) Stemmer Sign
(+) Weak dorsalis pedis
(-) Muscle Spasm
(-) Tightness
ROM:

Findings: All jts. of (B) UE/LE are actively and passively done WNL pain free c
N EF except:
Motion

AROM

PROM

NORMA
L
0 - 50
0 - 20
0 - 20

END
FEEL
SOFT
SOFT
SOFT

(R) Ankle PF
0-36
0-40
(L) Ankle DF
0-5
0-10
(R) Ankle DF
0-5
0-15
(L) Ankle
SOFT
0-20
0-25
0 - 35
eversion
(R) Ankle
SOFT
0-20
0- 24
0 - 35
eversion
(L) Ankle
FIRM
0-9
0-11
0 - 15
inversion
(R) Ankle
FIRM
0-10
0-13
0 - 15
inversion
Sig: LOM 2 edema
MMT:
Findings: All major (m) o (B) UE&LE are measured using the break test and
are grossly graded 5/5
Sig: For baseline date
Neurologic Examination:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for P.
Findings: Pt. has intact sensation as to pain, light touch and pressure except
for 50 % diminished light touch sensation on B legs and feet
Significance 2o edema
DTR:

(R)

(L)
Legend: 0 areflexia
+
hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

+
+

+
+
++
++
++

++
++
++

Findings: Hyporeflexia on (B) Achilles tendon reflex

Sig: 20 Edema
ANTHROPOMETRIC MEASUREMENT:
LIMB GIRTH MEASUREMENT:
Findings:
LANDMARK
2 Up

RIGHT
28cm

LEFT
26cm

Medial
Malleolus
2 Down
2 Up
MTP
2 Down

31cm

29cm

27cm

28cm

41cm
37cm
38cm

43cm
37 cm
40cm

Sig.: 20 Edema
LEG LENGTH MEASUREMENT:
Findings:
Landmark
TLL
ALL

ASIS to
Medial
Malleolus
Umbilicus to
Medial
Malleolus

RIGHT

LEFT

DIFFERE
NCE

86cm

85cm

0cm

86cm

87cm

1cm

Sig.: for baseline dat

ST:
Stemmers Test
Findings: cant pinch and skin lift
Sig: (+) edema
GAIT ASSESSMENT:
Findings: Antalgic gait pattern
Sig.: 20 pain
FUNCTIONAL ANALYSIS:
Self-care
Feeding: 7
Grooming: 7
Dressing: 5
Bathing: 6
Toileting: 6
Bed mobility
Roll to right: N/A
Roll to left: N/A
Supine to sit: 7
Sit to supine: 7
Transfers
Bed to chair: 7
Sit to stand: 7
W/c to toilet: N/A
Ambulation: 5

7
6
5
4

FIM LEVEL
Complete Independence
Modified Independence
Supervision
(100%)
Minimal Assistance
(75%)
Moderate Assistance

3
(50%)
2
Maximal Assistance
(25%)
1
Total Assistance

A:
PT Impression: Pt is a 36 y/o female pt diagnosed c type II DM and manifests
lymphedema on B legs and feet. Pt. complains of numbness and
pins and needles sensation on B feet causing her to have min-mod
difficulty in doing ADLs, such as doing household chores and
walking.
Procedural Intervention: PT proposes compensatory and preventative
interventions. Compensatory because symptoms are caused by
underlying condition: type II DM. preventative because PT mx can
be included so as to prevent further complications
Rehabilitation Prognosis: Good. Pt. is cooperative and has good support system.
Also pt. has shown great improvements by meds alone.
Problem List:
Problem List

STG

LTG

Edema on B legs and

ankles

Pt will have decrease

edema by 50% w/n 3
wks of PT Tx Sessions

Pt edema will decrease

by 90% or will be
eliminated after 6 wks of
PT Tx sessions
Pt. will achieve optimum
ROM on B ankles w/n 6
wks of PT Tx sessions

LOM of motion on R
ankle AP and L ankle
(Flexion, Extension,
Eversion and Invertion)

Pt will have increase

ROM by 5 increments on
B ankles w/n 3 wks of PT
Tx Sessions

Pt has 50% diminished

sensation on B legs and
ankles

Pt sensation will be
restored by 25% w/n 3
wks of PT Tx Session

Pt sensation will be near

normal- normal w/n 6
wks of PT Tx session

Pt has mod difficulty in

Ambulation

Pt will have min

difficulty performing
Ambulation w/n 3 wks of
PT Tx sessions

Pt will have no difficulty

performing Ambulation
w/n 6 wks of PT Tx
sessions

Pt has Antalgic gait

Pt will demonstrate near

normal gait pattern w/n
3 wks of PT Tx sessions

Pt will have normal gait

pattern/n 6 wks of PT Tx
session

Pt has min-mod
difficulty in performing
ADLs such as doing
household chores,
Dressing and
ambulation

Pt will have min

difficulty difficulty in
performing ADLs such
as doing household
chores, Dressing and
ambulation w/n 3 wks of
PT Tx sessions

Pt will reach optimum

performance on doing
ADLs such as doing
household chores,
Dressing and
ambulation w/n 6 wks of
PT Tx sessions

P:
Suggested Mx:
1. Effleurage on B LE x 5 mins to facilitate lymphatic drainage
2. Petrissage on B LE x 10 mins to facilitate lympathic drainage
3. PROM & AROM Exercise AP x 5 reps x 3 sets to in order to increase the
effectiveness of ankle pump
4. Gradient elastic stocking
5. Pt. education on present condition
6. HEP
Precaution:
1. HTN

PREPARED BY:
CASIL, GABRIELLE PAULINE C.
JALBUNA, JUDY FE D.
CRUZ, WENZY RAZZIE P.
MARZAN, CHRISTIAN E.
IMPERIAL, CHARMAINE E.