DOCUMENTATION CODE: F-MS-RMED008

REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014

Republic of the Philippines

Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER

Department of Rehabilitation Medicine

Capitol Compound Cagayan de Oro City

OUTPATIENT PHYSICAL THERAPY EVALUATION

INITIAL EVALUATION
NAME:

AGE:

Blasco, Demitrio

ADDRESS:

30

HANDEDNESS:
R

Bugo, CdOC

OCCUPATION:
INFORMANT:

SEX: M

machine operator

patient

REFERRING MD: Dr.

Bautista
SIGNATURE:

RE-EVALUATION
MARITAL STATUS:

Single
RELIGION: R.C
DATE OF IE/RE:
(MM/DD/YY)

BIRTHDATE:
(MM/DD/YY)
11/14/1985
HEALTH RECORD No.
972295
CONTACT NUMBER:
09215777205

11/13/2015
TREATMENT SCHEDULE: (MON-TUE-WED-THU-FRI)
M-W-F

REFERRAL DIAGNOSIS: Flexion contracture L hand

/S/
Pt. stated "lisod ipiko akong wala nga mga tudlo"
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Pt current condition started last 08/12/15; pt was on duty @ Galvasteel
when he accidentally inserted his L hand while inserting yero on durarib
machine. His coworkers helped him et was rushed to COMC at around 10
am; at 1:00 pm he had undergone operation c Dr. Kho et was admitted 3
days under general anesthesia.
On 09/2/15, he had undergone open wound operation by Dr. Kho d/t
darkening of the wound site; pt had his check-up on Oct. 10 et was seen c
flexed fingers c inability to extend; he was then referred to Dr. Antolin et on
Oct. 18 he had undergone G plus operation to release the flexor tendons of
the L hand. After the operation, pt had his weekly check-up et was referred
to rehab.

X-ray
@ NMMC (08/12/15, 10/18/15, 11/12/15)
ANCILLARY PROCEDURE (with
dates):

MEDICATION:
none
PAST MEDICAL HISTORY:
Hospitalization 2 dengue (2005)

FAMILY HISTORY:
(-) heredo-familial disease
(+) occasional drinker
PERSONAL & SOCIAL HISTORY:
plays basketball ; lives c his sister
PRIOR LEVEL OF FUNCTION:
(+) ambulatory
indep. in all ADLs; currently stopped working et stays only at home
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N/AMATERNAL HISTORY:
(Prenatal-Perinatal-Postnatal)

N/A

MILESTONE:

GOAL:
gusto na koPATIENT'S
makabalik
og trabaho as stated by the pt.

Republic of the Philippines

Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER

DOCUMENTATION CODE: F-MSRMED-008

REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014

Department of Rehabilitation Medicine

Capitol Compound Cagayan de Oro City

OUTPATIENT PHYSICAL THERAPY EVALUATION

/O/
VITAL SIGN:

BEFORE Tx: BP:

PR:
RR:

130/90
92
22

DURING Tx: 110/70

BP: 98
PR: 22
RR:

(+) ambulatory
OCCULAR INSPECTION:
(+) mesomorphic
(+) scars on L FA et hand
(+) open wound L palm
(+) skin discoloration on L hand

Pt is C/C/C, alert et oriented as to P/P/T

NEUROLOGIC EXAM:
(+) intact sensation

(+) normothermic
PALPATION:
(+) non-pitting edema on L thenar eminence

(+) normotonic

MUSCLE TONE
ASSESSMENT:

DEEP TENDON REFLEX:

N/A
PATHOLOGIC REFLEX:

N/A
PRIMITIVE REFLEX:

R
REMARKS:

Page 2 of 5

SPECIAL TEST:
N/A

110/70

AFTER Tx: BP: 84

PR: 18
RR:

jerbug14

DOCUMENTATION CODE: F-MSRMED-008

REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014

Republic of the Philippines

Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER

Department of Rehabilitation Medicine

Capitol Compound Cagayan de Oro City

OUTPATIENT PHYSICAL THERAPY EVALUATION

RANGE OF MOTION AND MANUAL MUSCLE TEST
REMARKS:
ROM and MMT of both UE and LE are WNL and grading except:

ACTIVE

PASSIVE

NORMA
L

CURRENT
ACTIVE

MOTION

Wrist flexion

070
040
060

Wrist extension
MCP flexion

END-FEEL

PASSIVE
R

Firm

3-/5

0-44

0-70

Firm

3-/5

0-75

0-90

Firm

2-/5

SCOR
E
2
2

1
2
2
3
3
2
2
1
20

REMARKS:

COORDINATION & BALANCE TESTS:

GRADE:
LEFT

0-80

TOTA
L

0-76

FUNCTIONAL TEST:
ACTIVITY
BOWEL
BLADDER
GROOMIN
G
TOILET
USE
FEEDING
TRANSFER
MOBILITY
DRESSING
STAIRS
BATHING

MMT

COORDINATION TEST
Finger to nose
Finger to therapists
finger
Finger to finger
Alternate nose to finger
Finger opposition
Rebound phenomenon
Tapping (hand)

GRADE:
RIGHT

REMARKS
N/A

Alternate heel-to-knee;
heelto-toe
Heel-to-shin
Tapping (foot)
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Republic of the Philippines

Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER

DOCUMENTATION CODE: F-MSRMED-008

REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014

Department of Rehabilitation Medicine

Capitol Compound Cagayan de Oro City

OUTPATIENT PHYSICAL THERAPY EVALUATION

BALANCE TEST
Standing in a normal comfortable posture
Standing, feet together (narrow BOS)
Standing in tandem position, with one foot
directly in
front of the other (toe of one foot touching
heel of
opposite foot)
Standing on one foot
Arm position may be altered in each of the
above
postures (i.e., arms at side, overhead, hands
on waist)
Perturbations: displace balance
unexpectedly (while
carefully guarding the patient)
Standing, functional reach: forward trunk
flexion with
UE
reach
Standing, laterally flex trunk to each side
Tandem walking, placing the heel of one foot
directly
in front of the toe of the opposite foot.
Standing in tandem position eyes open to
eyes closed

GRAD
E

REMARKS
N/A

Key to grading:
5

Normal performance

Minimal impairment: able to accomplish; slightly less than normal speed; requires supervision/ minimal
contact guarding

Moderate impairment: able to accomplish activity; movements are slow, awkward, & unsteady;
requires moderate contact guarding

Severe impairment: able only to initiate activity without completion; requires maximal
contact guarding

Activity impossible

POSTURAL ANALYSIS
REMARKS:
Pt. was seen c slight

lumbar lordosis

1
0
1
0
1
0
1
0
5

1
0

Total Score

Page 4 of 5
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55/60

Republic of the Philippines

Center for Health Development- X
NORTHERN MINDANAO MEDICAL CENTER

DOCUMENTATION CODE: F-MS-RMED008

REVISION No.: 0
DATE EFFECTIVE: DECEMBER 2014

Department of Rehabilitation Medicine

Capitol Compound Cagayan de Oro City

OUTPATIENT PHYSICAL THERAPY EVALUATION

GAIT ASSESSMENT/ANALYSIS:
REMARKS:
Pt has N gait pattern

JOINT

INITIAL
CONTACT

MIDSTANCE

PUSH-OFF

SWING

HIP
KNEE
ANKLE

GROSS/MOTOR SKILL ASSESSMENT

REMARKS:
Can perform gross motor skills s difficulty

/A/
PT IMPRESSION:
Pt has difficulty performing L hand movements 2 flexion contracture

PROBLEM LIST: 1. (+) LOM on L wrist et hand

2. mm weakness on L hand
3. poor gripping strength on L hand

LONG TERM GOAL:1. Pt will have a WNL ROM on L wrist flex et ext, et MCP flexion within 12 tx
sessions
2. Pt will have mm strength on L MCP flexors et ext. from 2-/5 5/5 within
12 tx sessions
3. Pt will have mm strength on L wrist flexors et ext. from 3-/5 5/5 within
12 tx sessions

SHORT TERM GOAL:

4. Pt will have an ROM of 10 on L wrist flex et ext, et MCP flexion within 6
tx sessions
5. Pt will have mm strength on L MCP flexors et ext. from 2-/5 3/5 within 6
tx sessions
6. Pt will have mm strength on L wrist flexors et ext. from 3-/5 3+/5
within 6 tx sessions

/P/
PT MANAGEMENT: 1. HMP on L hand x 15 min x 2 sets; done alternately c AAROME
2. AAROME on L hand x 10 reps x 2 sets
3. Stretching on L wrist fl et ext.; finger fl et ext; finger abd/add x 10 reps c
10SH x 2 sets
4. Strengthening ex. on L hand c squeeze ball x 10 reps c 10SH x 2 sets
5. Pt. education
6. HEP

EVALUATED BY:
PHYSICAL THERAPY INTERN
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