Physiotherapy Home Visit Note

Physiotherapist Subjective: - Verbal consent obtained for assessment and treatment during this session. - Patient reported new onset of right knee pain, insidious in nature, over the last 3 days. - Characteristics of new symptom: - Duration: 3 days - Timing: Worse with activity, especially stairs and prolonged standing. - Location: Anterior aspect of the right knee, around the patella. - Quality: Dull ache, occasional sharp twinges with movement. - Severity: 5/10 at worst, 2/10 at best. - Context: Started after an unusually long walk. - Factors that worsen or relieve new symptoms and any self-treatment attempts and their effectiveness: - Worsened by: Stairs, prolonged standing, initial movement after rest. - Relieved by: Rest, ice application (reported moderate effectiveness). - Self-treatment: Paracetamol, 500mg, twice daily (reported mild relief). - Progression of new symptoms over time: Pain has remained consistent since onset, no significant improvement or worsening. - Previous episodes of new symptom including how they were managed and their outcomes: Patient reports a similar episode 2 years ago, managed with rest and over-the-counter pain relief, resolved within 2 weeks. - Impact of new symptom on daily activities including work, home and physical activity: Patient finds it difficult to climb stairs in her home, which are essential for accessing the bedroom and bathroom. Gardening, a favourite hobby, has been significantly curtailed. Walking distance is limited to approximately 10 minutes before pain increases. - Associated or systemic symptoms accompanying the main new complaint: No associated swelling, redness, locking, giving way, or systemic symptoms reported. - Investigations reported by the patient or a relative including completed results and any planned or pending investigations: Patient reports no investigations have been performed. No investigations are currently planned. - Summary of any advice, education or counselling provided by the clinician during the visit: Patient was advised on activity modification and pain management strategies, including the RICE principle. Education was provided regarding patellofemoral pain syndrome. Objective: - This is a follow-up home visit. - Chief reason for ongoing input: Management of chronic low back pain and now new onset right knee pain. - Mrs. Sarah Jenkins, the patient's daughter, was present during the visit. - Vital signs: - Blood Pressure: 130/80 mmHg - Heart Rate: 72 bpm - Respiratory Rate: 16 breaths/min - Temperature: 36.8°C - Physical or mental examination findings organised by body system or clinical relevance in the order they were mentioned: - Right Knee Inspection: Mild swelling noted around the patella. No redness or ecchymosis. - Right Knee Palpation: Tenderness along the medial and lateral patellar facets. No crepitus with passive movement. - Right Knee Range of Motion: Flexion 0-130° (pain at end range), Extension 0-5° (full). Left knee full range of motion, pain-free. - Strength (Manual Muscle Testing): Right Quadriceps 4/5 (pain with resisted extension), Right Hamstrings 5/5. Left lower limb strength 5/5 throughout. - Functional Assessment: Patient demonstrated difficulty ascending and descending 3 steps in the home, requiring bilateral handrail support and reported 6/10 pain with this activity. Gait analysis showed a slight antalgic gait favouring the left leg. - Exercises performed during the session: - Quadriceps sets: Patient performed 3 sets of 10 repetitions, focusing on isometric contraction. Therapist provided verbal cues for proper technique. - Straight leg raises: Patient completed 2 sets of 10 repetitions, supine. Progressed from active-assisted to independent with good form. - Patellar mobilisations: Therapist performed passive patellar glides, medial and lateral, for 2 minutes each side to improve patellar mobility. Patient reported slight discomfort initially, decreasing with sustained pressure. - Treatment modalities used during the session: - Heat pack application to right knee for 15 minutes to reduce muscle guarding and improve tissue extensibility. Patient reported comfort. Assessment: - Clinician's explicitly stated diagnosis or clinical impression of any new symptoms or issues: The patient presents with acute patellofemoral pain syndrome of the right knee, likely exacerbated by recent increased activity. - Brief overall analysis of movement patterns if not already documented under a specific exercise or treatment in the objective section: Patient demonstrates good motor control during unweighted exercises but shows compensation patterns during weighted functional tasks, particularly stair climbing. - Brief clinical interpretation of today's findings including overall performance, performance changes, response to intervention and whether findings are consistent with the ongoing presentation or represent a change: Today's findings are consistent with the patient's reported new onset right knee pain and align with a diagnosis of patellofemoral pain syndrome. The patient responded positively to initial interventions, showing improved comfort with patellar mobilisations and good engagement with therapeutic exercises. This represents a new clinical presentation in addition to the patient's chronic low back pain. Plan: - Future treatment planned, progressions planned or review points for future visits: - Continue home exercise program (HEP) focusing on quadriceps strengthening, hip abduction, and gluteal activation. - Progress stair negotiation by focusing on eccentric control during descent. - Review pain levels and functional ability at next visit. - Introduce proprioceptive exercises as pain allows. - Any referrals, follow-up plans or allied health involvement: - Follow-up physiotherapy home visit scheduled for 1 November 2024 to review progress and advance HEP. - No further referrals currently indicated.