LORMA COLLEGES

INITIAL EVALUATON

General Information:
Pts Name:
Age: 20y/o
Sex: M
Address: Gov. Lucero St. City of San Fernando, La Union
Civil Status: Single
Handedness: Right
Occupation: N/A, Student
Referring Unit: OPD
Referring MD: Dr. C.P
Rehab MD: N/A
Date of Consultation: 10-31-16
Date of Referral: N/A
Date of IE: 11-4-16
Diagnosis: Community Acquired Pneumonia

S:
c/c: Pt. complains of chest pain, fatique and difficulty in breathing.
HPI: Present condition started 4 years ago PTIE, when pt. was in 3 rd yr high
school, when pt. experienced sudden, deep nagging pain on her chest c
radiating pain on the whole UE (P/S 5/10). Pt. condition reoccurs in side
lying position or sitting in a slouched position without back rest and
relived by supine position as her comfortable position. Pt. ignore the pain
and other symptoms and did not take any medications because pt.
thought it was an ordinary case. Before the condition happen, pt. can
perform ADLs such as cleaning the dishes, wiping the floor, cleaning the
house and doing outdoor activities like badminton and jogging around
oval (~1m) for 6 rounds.
A week PTIE, pt. felt and notice an episodic chest pain when pt. was in
high school. Pt. condition last for 5-10 min every afternoon and easily get
tired, fatigue and experience SOB. Pt.s mother is worried with her
condition which prompted the pt. to ask for a medical advice at LMC by
Dr. J. A and was recommended to have a 2D echo and laboratory test (see
ancillary procedure)
At present, pt. has difficulty in doing ADL S such as cleaning the
dishes, wiping the floor, cleaning the house and doing outdoor activities
like badminton and jogging around oval (~1m) for 6 rounds.

ANCILLARY PROCEDURES:

PROCEDURE
ECG
hematology
2D echo

DATE/PLACE
LMC/ 11/18/16
LMC/ 11/18/16
LMC/ 11/21/16

FINDINGS
(+) sinus arrhythmias
No significant findings
Minimal post Cu-desac fluid

PRESENT MEDICATION
Name of Medicine
carvedilol

Dosage
12. 5mgx q.a.m &

Trymetazidin
Spironolactone
Celocoxib

pm
35mg x bid
25 mg c OD (mwf)
200mgx OD p.r. n

PMHx: Pt. has previous hx of hospitalization , (+) allergy & (-) HTN, DM, Asthma.
Date

Hospital

Reason

2007 (exact date

Tablac hospital, candon

Tonsillitis

unrecalled)

city

FMHx:
Pathology
Heart dse.
HTN
Asthma
DM

Mother
(-)
(-)
(-)
(-)

Father
(+)
(+)
(-)
(-)

PSHx: Pt. has an active lifestyle, she exercise regularly like jogging and walking. Pt.
walk to school ~ 300m. Pt. has no hx of any substance abuse, a non-alcoholic
beverage drinker and a non-smoker. Pt. lives in a 2 storey house c her family. Pt.
room is situated at the 2nd floor BR CR ~ 7m, BR kitchen~ 12m, BR maindoor~
10m
Goal: Sana mawala sakit ko

O:
VS: BP-120/80 mmHg
PR -95 bpm
RR -12cpm
T - 36.4C
OI:
Manner of Arrival: Amb s AD
Mental Status: A/C/C
Physique: Ectomorph

Postural Deviation: (+) (see PA)

GA : (-)
Atrophy: (-)
Swelling; (-)
Trophic Skin changes : (-)

Palpation:
Thermal Assessment: Normothermic in all exposed body parts
Tone Assessment: hypertonic on both upper trapezius
Muscle Spasm: (-)
Tenderness : (-)
Auscultation:
(+) skip beats on T9
ROM:
Findings: All major joints of (B) UE/LE are WNL actively and passively done,
pain free c N end-feel
Sig: for base line data
MMT:
Findings: All major muscles on B UE/LE, neck and trunk are grossly assesses
and are grossly graded 5/5 in MMT.
Sig: for base line data
ST:
Findings: N/A
Sig: N/A
PA:
ANTERIOR
R shoulder higher than
L

Neurologic Examination:
Sensory Testing:

POSTERIOR
R shoulder higher than
L

LATERAL
Slouched posture

Device Used: Pin for pain, brush for light touch, thumb for P.
Findings: Pt. has intact sensation as to pain, light touch and pressure
Significance: for baseline data
DTR:
(R)

(L)
+
+

+
+
++
++

++
++
0

Legend:
Legend:
0 areflexia
+
hyporeflexia
0 areflexia
++ normoreflexia
+++ hyperreflexia
+ hyporeflexia
++++ clonus
++ normoreflexia
+++ hyperreflexia
++++ clonus

++

Findings:
Pt. is normoreflexive on B UE/ LE.
Sig:. intact reflex arch
FA:
Self-care
Feeding: 7
Grooming: 7
Dressing: 7
Bathing: N/A
Toileting: N/A
Bed Mobility
Roll to right: 7
Roll to left: 7
Supine to sit: 7
Transfer:
Bed to chair: 7
Sit to stand: 7
Ambulation: 6
6 Minute walk test
Pt was able to walk 300m

Findings: pt was able to do the test without any problem

12 minute walk test
Pt was able to walk 400m
Findings: pt. felt chest pain, fatique and SOB p walking 105

A:
PT Impression: Pt. has a moderate difficulty in performing ADLs such as
household chores, climbing stairs, and walking due to edema and
difficulty in breathing.
Procedural intervention: Pt. proposes a compensatory and preventive
intervention because she is cooperative and alert. 3Tx session/wk for 3
mos.
Prognosis: Pt. has a moderate prognosis to his rehab. Since there is no
adverse effect noted. Pt. has a supportive family.
Problem List
1. Pt. c/o difficulty in
breathing
2.Pt. has a difficulty in
walking
3.Pt. has moderate difficulty
in doing ADLs

STG
To difficulty in breathing
and can perform the Mx
given c SOB within
2 wks
Pt will demonstrate N gait
pattern upon verbal cue p 2
wks
To eliminate difficulty in
performing ADLs such
household chores, stair
negotiation.etc. within 2wks.

P:
PT Mx:
1. FES on (L) and (R) ankle x 15'
2. PROMEs on (L) and (R) ankle x 20 reps x 1 set
3.

LTG
Pt. Can perform and
demonstrate all the Mx.
Given to near N function
within 6 wks.
To maintain N normal gait
pattern p 5 wks
To maintain optimum
capacity in performing ADLs
such household chores, stair
negotiation.etc. within 5wks.