Physical Therapy Daily Note Example: Post-Operative Intertrochanteric Femoral Fracture

For a 68-year-old male five days post-ORIF of a left intertrochanteric femoral fracture with hypertension and type 2 diabetes, the physical therapy daily note should prioritize early mobilization with weight-bearing as tolerated, multimodal analgesia optimization, infection surveillance, and documentation of functional progress toward re-enablement goals.

Patient Information & Surgical Status

Date: [Current Date]
Post-Operative Day: 5
Diagnosis: Left intertrochanteric femoral fracture, status post open reduction internal fixation
Medical History: Hypertension (controlled on lisinopril 10 mg daily), Type 2 diabetes mellitus (controlled on metformin 500 mg BID)
Current Medications: Lisinopril 10 mg daily, metformin 500 mg BID, acetaminophen 650 mg q6h PRN pain
Weight-Bearing Status: Weight-bearing as tolerated with walker 1

Subjective Assessment

Pain Level: Patient reports 4/10 at rest, 6/10 during activity 2
Functional Complaints: Difficulty with transfers, limited ambulation distance, reports fatigue during mobilization
Sleep Quality: Adequate; no reports of nocturnal pain interfering with rest
Bowel/Bladder Function: Document any constipation, urinary retention, or incontinence as these complications interrupt re-enablement 1, 3
Cognitive Status: Alert and oriented; screen for signs of postoperative delirium (confusion, agitation, inattention) which occurs in 25% of hip fracture patients 1, 3

Objective Assessment: Infection Surveillance

At five days post-operative, aggressive screening for fracture-related infection is the highest priority 4:

Wound Inspection: No purulent drainage, no wound dehiscence, no sinus tract formation, incision edges well-approximated with minimal erythema 4
Local Signs: No increased warmth, no new or worsening swelling beyond expected post-operative edema, no new joint effusion 4
Systemic Signs: Afebrile, no constitutional symptoms (malaise, chills) 4
Pain Pattern: Pain level consistent with expected post-operative course; new-onset or worsening pain would raise suspicion for infection 4

Clinical Pitfall: Purulent drainage, wound breakdown communicating with the implant, or presence of a sinus tract definitively confirms infection and requires immediate surgical consultation 4. Document and report any of these findings immediately.

Objective Assessment: Functional Measures

Range of Motion

Left Hip Flexion: 65° (limited by pain and protective guarding)
Left Hip Extension: 5° (patient supine)
Left Knee Flexion/Extension: Within functional limits
Left Ankle Dorsiflexion/Plantarflexion: Within functional limits

Strength (Manual Muscle Testing)

Left Hip Flexors: 3/5 (fair, against gravity only)
Left Hip Extensors: 3/5 (fair)
Left Quadriceps: 3+/5 (fair plus)
Left Ankle Dorsiflexors: 4/5 (good)

Functional Mobility

Bed Mobility: Modified independent with bed rails for rolling and supine-to-sit transitions
Sit-to-Stand: Contact guard assistance required, uses bilateral upper extremity support on walker
Ambulation: Contact guard assistance with standard walker, weight-bearing as tolerated on left lower extremity, ambulated 50 feet in hallway with two rest breaks 1
Gait Pattern: Antalgic gait favoring left side, decreased stance time on left, reduced step length bilaterally

Pain Management Optimization

Inadequate analgesia at five days post-operative impedes mobilization and increases risk of life-threatening thromboembolism 4:

Current Regimen Assessment: Acetaminophen 650 mg q6h PRN is insufficient as foundational analgesia 2
Recommendation to Medical Team: Schedule acetaminophen 1000 mg every 6 hours (not PRN) as mandatory baseline treatment to decrease supplementary analgesic requirements 2, 4
NSAID Consideration: Given patient's hypertension and potential renal considerations with ACE inhibitor use, NSAIDs should be avoided unless renal function is confirmed normal 2
Opioid Use: Current PRN acetaminophen-only regimen may necessitate breakthrough opioid use; however, opioids should be reserved strictly for rescue therapy and minimized due to increased risk of postoperative cognitive dysfunction, constipation, and urinary retention 2, 3
Regional Anesthesia: If pain remains 6/10 with activity despite optimized oral analgesia, consider consultation for fascia iliaca compartment block or femoral nerve block to facilitate mobilization 1, 2

Clinical Pitfall: Pain scores should be documented both at rest and during movement; discrepancies between resting and activity pain guide rehabilitation intensity and analgesic adjustments 2, 4.

Mobilization & Thromboembolism Prevention

Early weight-bearing after femoral fracture ORIF reduces the prevalence of deep vein thrombosis (1-3%) and pulmonary embolism (0.5-3%) 4:

Today's Session: Patient ambulated 50 feet with walker, weight-bearing as tolerated on left lower extremity, contact guard assistance required 1
Toe-Off and Ankle-Pump Exercises: Instructed patient in active ankle dorsiflexion/plantarflexion exercises (10 repetitions every hour while awake) to further lower thromboembolic risk 4
VTE Prophylaxis Verification: Confirmed patient adherence to prescribed anticoagulant prophylaxis (document specific agent if known, e.g., enoxaparin) 1
DVT/PE Screening: No unilateral leg swelling, no calf tenderness beyond surgical site, no shortness of breath, no chest pain, no tachycardia 4

Clinical Pitfall: Delaying mobilization due to pain concerns increases thromboembolism risk more than it protects the surgical site 4. Optimize analgesia to enable mobilization rather than restricting activity.

Therapeutic Interventions

Strengthening Exercises

Quadriceps Sets: 3 sets of 10 repetitions, bilateral, to maintain muscle activation and prevent atrophy 5, 6
Gluteal Sets: 3 sets of 10 repetitions, bilateral, to support hip extension strength 5, 6
Ankle Pumps: 10 repetitions every hour while awake for DVT prophylaxis 4
Straight Leg Raises: Attempted on right (uninvolved) side; deferred on left due to pain and protective guarding 5, 6

Transfer Training

Supine-to-Sit: Practiced with bed rails, modified independent 6
Sit-to-Stand: Practiced from bedside chair and toilet height surfaces, contact guard assistance, emphasis on equal weight distribution and use of upper extremities on walker 6

Gait Training

Walker Ambulation: 50 feet in hallway, weight-bearing as tolerated on left, contact guard assistance, two rest breaks required 1
Gait Pattern Correction: Verbal cues provided to increase stance time on left lower extremity and normalize step length 6
Stair Training: Deferred until pain control improves and strength increases to 4/5 in hip flexors/extensors 6

Patient Education

Hip Precautions: Reviewed avoidance of excessive hip flexion beyond 90°, avoidance of hip adduction past midline, and avoidance of internal rotation to protect surgical fixation 5, 6
Home Exercise Program: Provided written instructions for quadriceps sets, gluteal sets, ankle pumps, and seated hip flexion exercises 5, 6
Fall Prevention: Educated on environmental hazards (rugs, clutter, poor lighting), use of assistive device at all times, and importance of requesting assistance for transfers 1

Nutritional & Hydration Status

Appetite Assessment: Patient reports fair appetite, consuming approximately 60% of meals 4
Oral Fluid Intake: Encouraged to drink at least 1500-2000 mL daily to avoid hypovolemia and support renal function, particularly important given ACE inhibitor use 2, 4
Nutritional Concern: Up to 60% of fracture patients are malnourished on admission, which adversely affects bone healing and overall recovery 4
Recommendation: Coordinate with dietitian for nutritional assessment and supplementation if intake remains suboptimal 4

Clinical Pitfall: Hypovolemia remains common at five days post-operative; encourage oral fluid intake rather than routine IV fluids 2.

Medication Considerations for Physical Therapy

Lisinopril (ACE Inhibitor)

Orthostatic Hypotension Risk: Monitor blood pressure before and after mobilization; ACE inhibitors can contribute to postural hypotension, particularly in the setting of hypovolemia 7
Renal Function: ACE inhibitors require caution if renal function is impaired; this influences NSAID safety and opioid dosing 2, 7

Metformin (Oral Hypoglycemic)

Hypoglycemia Risk: Although metformin alone rarely causes hypoglycemia, monitor for signs of low blood sugar (shakiness, confusion, diaphoresis) during exercise sessions, particularly if patient has not eaten 8
Perioperative Management: Diabetes is not a reason to delay mobilization unless patient is ketotic or severely hyperglycemic 1

Acetaminophen

Current Dosing Inadequate: PRN dosing at 650 mg q6h does not provide consistent analgesia; recommend scheduled 1000 mg q6h to establish baseline pain control 2, 4

Clinical Pitfall: Cyclizine (antiemetic) should be avoided due to antimuscarinic side effects that increase delirium risk in this population 2, 3.

Assessment & Clinical Reasoning

Functional Status: Patient is progressing toward re-enablement goals (resuming activities of daily living between days 2-5 post-surgery) but is limited by pain during activity (6/10) and reduced lower extremity strength (3/5 hip flexors/extensors) 1
Pain Management: Current PRN acetaminophen regimen is insufficient; scheduled dosing at 1000 mg q6h is required to facilitate mobilization and reduce opioid requirements 2, 4
Infection Risk: No current signs of fracture-related infection; continued vigilance required as biofilm maturation occurs over weeks 4
Thromboembolism Prevention: Patient is mobilizing with weight-bearing as tolerated, which is the most effective DVT/PE prophylaxis; ankle pumps and continued ambulation are critical 4
Cognitive Status: No signs of postoperative delirium; maintain multimodal optimization (adequate analgesia, hydration, electrolyte balance, early mobilization) to prevent delirium development 1, 3

Plan for Next Session

Increase Ambulation Distance: Goal of 100 feet with walker, weight-bearing as tolerated, with fewer rest breaks as pain control improves 1, 6
Progress Strengthening: Advance to resisted hip flexion/extension exercises using resistance band if pain permits 5, 6
Initiate Stair Training: Assess readiness for stair negotiation based on hip flexor/extensor strength (goal 4/5) and pain control 6
Continue Transfer Training: Progress toward modified independence with sit-to-stand transfers 6
Reassess Pain Management: Follow up on recommendation for scheduled acetaminophen 1000 mg q6h; document pain scores at rest and with activity to guide further analgesic adjustments 2, 4
Monitor for Complications: Continue surveillance for infection signs, DVT/PE symptoms, and cognitive changes 1, 4, 3

Discharge Planning Considerations

Home Safety Assessment: Coordinate with occupational therapy to assess home environment for fall hazards (stairs, rugs, bathroom safety) and need for durable medical equipment (elevated toilet seat, shower chair, grab bars) 1, 4
Assistive Device: Patient will require walker for ambulation at discharge; ensure proper fit and patient/caregiver education on safe use 1
Caregiver Support: Assess availability of caregiver assistance at home for transfers, meal preparation, and medication management 1
Outpatient Physical Therapy: Recommend continuation of physical therapy 2-3 times per week for 6-8 weeks to restore strength, range of motion, and functional independence 5, 6, 9

Physical Therapist Signature: [Name, PT, DPT]
Date: [Current Date]
Time: [Session Time]

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