Ci Copy Soap

Danielle Fetterolf, SPT
SOAP Note 2
The patient is a 66-year-old male seen in the hospital for D/C planning and mobility consult
following a L THA secondary to OA. Pt. did not have a significant past medical history and no
prior orthopedic surgeries. On first day post-op pt. was still dealing with aftermath of anesthesia
and during PT examination, had an episode of orthostatic hypotension when standing for the first
time after surgery which caused an extended hospital stay. This note is for the follow up PT visit
on the second day post-op.
S – Subjective
Pain at the beginning of session reported as 2/10. In the last 24 hrs, the highest and lowest pain
pt. experienced was 5/10 and 1/10. Pt. reports feeling less drowsy and under the effects of
anesthesia today than yesterday. Pt. would like to be discharged home from the hospital today
and return to recreational activities as quickly as possible.
O – Objective
Status Update:
- HR was 72 bpm and BP was 124/76 mmHg at the start of session. HR was 86 bpm and
BP was 130/74 mmHg upon standing.
- 5 time sit to stand from bed took 12.7 seconds with pt. using arms, FWW, and CGA.
- TUG from chair using FWW and WBAT LLE took 7.7 seconds to complete.
- R hip flexion strength 248 N and L hip flexion strength 194 N measured with
dynamometer at 20 degrees of flexion in supine.
- R hip extension strength 172 N and L hip extension strength 138 N measured with
dynamometer at 10 degrees of extension while standing.
- AROM of R hip extension was 35 degrees. AROM of L hip extension was 20 degrees.
- Gait Assessment: Pt. able to AMB 25 ft WBAT LLE with FWW and CGA using modified
3-point gait.
- Curb Step Assessment: Pt. able to ascend and descend curb step WBAT LLE with FWW
and CGA. Followed cues on up with good leg and down with bad leg and maintained
balance.
Interventions:
- BLE ankle pump 10 x 5 sec hold
- BLE glute set 10 x 5 sec hold
- BLE quad set 10 x 5 sec hold
- BLE supine heel slide 1 x 10 reps
- LLE supine hip abduction 1 x 10 reps
- LLE supine knee extension strengthening with rolled towel under knee 1 x 10 reps
- BLE seated long arc quad 10 x 5 sec hold
- BLE standing heel raise with UE support 1 x 10 reps
- LLE standing hip abduction 1 x 10 reps
- Sit to stand from chair 2 x 5 up and down with use of FWW and CGA
- AMB 2 x 100 ft using modified 3-point gait training with FWW and CGA
- Ice L hip 10 mins to reduce pain
- Educated pt. and wife on posterior hip precautions
o Do not bend trunk forward more than 90 degrees or raise your L knee above your
L hip
o Do not bring L leg past the center of your body / adducted L leg
o Do not rotate or twist L leg inward / invert L foot / rotate trunk to L without
moving L leg
- Educated pt. on HEP and benefits
o Should complete 2-3 times per day
o BLE ankle pump with 5 sec hold 3 x 10
o BLE glute set with 5 sec hold 3 x 10
o LLE quad set with 5 sec hold 3 x 10
o BLE supine heel slide 3 x 10 reps
o LLE supine hip abduction 3 x 10 reps
o Walk 5-10 minutes every hour
A – Assessment
Pt. is a 66 y/o male seen in the hospital on day 2 post-op L THA with posterior approach
secondary to OA. Vitals monitored throughout session due to episode of orthostatic hypotension
in previous session. Pt. struggled to maintain hip precautions during sit-to-stand transfers from
bed set at height of bed at home. Improved with cuing to keep L leg extended and moving to
higher surface of the chair. Time for 5 time sit-to-stand assessment shows that there is limited
functional mobility. TUG assessment did not show increased fall risk.
Goals:
P – Plan
Next visit discontinue exercises that pt. is doing as a part of HEP 2-3 times a day if pt. able to
teach back exercises. Add stair training 3x4 with L railing to mimic home environment and
practice carrying FWW up the stairs. Communicate pt. need for education regarding ADLs like
dressing without breaking posterior hip precautions.
ICF Model
- Health Condition
o L THA on 10/21/24 secondary to OA of L hip
- Body Functions and Structure
o Decreased stability of the L hip joint due to posterior surgical approach
o Patient reports 2/10 pain in L hip at rest
o Patient reports 4/10 pain with L hip extension past 20 degrees
- Activities
o Difficultly performing full AROM of L hip extension.
o Not allowed to perform AROM/PROM of L hip flexion beyond 90 degrees.
o Patient can AMB 100ft with FFW and CG x 1.
- Participation
o Patient is not able to participate in desired recreational activities at this time.
o Currently, the patient is not able to negotiate stairs inside his house to reach the
bedroom and full bathroom.
- Personal Factors
o Patient is a 66 yo male.
o The patient is an active individual who enjoys swimming, biking, and running as
recreational activities.
o Patient understands the movements/positions that he cannot do to comply with
posterior hip precautions.
- Environmental Factors
o Patient has a full flight of stairs within his house to reach the primary bedroom
and full bathroom but has the ability to live on the first floor of his house in the
guest bedroom and full bathroom.
o There is a toilet seat raiser installed on the toilet in the first floor full bath that the
patient will be using in order to comply with hip precautions.
o Patient lives with his wife, who is willing to aid recovery by encouraging
adherence to HEP and assisting with transfers.

Ci Copy Soap

Uploaded by

Copyright:

Available Formats

Ci Copy Soap

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ci Copy Soap

Uploaded by

Copyright:

Available Formats

Danielle Fetterolf, SPT

You might also like