INITIAL EVALUATION

General Information
- Patient’s Name : - Reffering Dr : Dr. Calgoso
- Age : y/o - Rehab Dr : Dr. Jolyn Ruth
- Gender : Male Ambasing, FRARM
- Address : Isabela - Date of Referral : April 17,2018
- Civil Status : Maried - Date of IE : April 17,2018
- Handedness : Left -Handed - Diagnosis : T/C piriformis
- Occupation : Farmer strain
- Religion : Roman Catholic
- Precautions:

c/c: Px c/o of intermittent, localized dull aching pain on L paracervical area c ps 4/10, L lower back c
ps 2/10 and difficulty in rotating his head. Aggravated every morning c ps 5/10 on L paracervical area,
ps 3/10 on L lower back and was relieved by applying applying oil liniment c ps 3/10 on L paracervical
area, ps 1/10 on L lower back .

HPI:
Present condition started ~ 1st wk of February 2018 when pt. felt an intermittent, localized dull
aching pain on L para cervical area c ps 6/10, L lower back c ps 5/10 p carrying heavy sacks of rice
~50 kg on his head and difficulty in rotating his head. Pt. managed the pain by rest and applying oil
liniment, a decrease of pain was noted from ps 6/10  5/10 on L para cervical area, from ps 5 /10
4/10 on L lower back. After ~ 1wk prior to the incident pt went to a masseur and a relieved of pain was
noted from ps 6/10  4/10 on L para cervical area, from ps 5 /10 3/10 on L lower back. On ~ 3rd wk
of February 2018 when pt wasn’t able to tolerate the pain and having difficulty in rotating his head this
prompted the px to seek medical consultation at Solas Medical Clinic, pt. was attended by Dr. Jed
Solas. Pt. was given medication (unrecalled) for pain relief which the pain from ps 6/10  5/10 on L
para cervical area, from ps 5 /10 4/10 on L lower back and was adviced to stop carrying heavy
loads.
On April13, 2018 d/t persistence of pain pt. went to Notre Dame De Chartes Hospital to seek
medical consulation under Dr. Calugoso a physiatrist. Pt. was requested to undergo X-ray (see ancillary
procedure) at the and was given a medication (see medication). Pt. was referred to Dr. Ambasing to
undergo PT session. On april 16, 2018pt went to SLU Sacred Heart hospital PT rehab . Patient was
attended by Dr. Ambasing, ancillary procedure was done. Patient was then diagnosed of having
and was given medication (see medication). Patient recommended him to undergo PT Rehab to
address his complain.

Ancillary Procedures:
Procedure/s Date/Hospital Results
X-ray April 13, 2018 Notre Dame De Unrecalled
Chartes Hospital
x-ray April 16, 2018 SLU Sacred No result yet
Heart hospital

Past Medical and Surgical History:

 - (-) Hospitalization
- (-) Surgery
- (-) HTN
- (-) Stroke
- (-) Accidents
- (-) Fall
- (-) Trauma
- (-) Heart disease
- (-) Diabetes
- (-) RA
- (-) Asthma
- (-) Scoliosis

Medications:

Generic Brand Dosage Indication

Celecoxib Celexib 1 tb 2x day Pain reliever

Personal, Social and Living Environment:

- Active lifestyle
- Pt works as farmer
- Pt spend 6 hrs in the farm his work involves carrying sacks of rice weighing ~50 kg on the top
of his head, walking ~300m when plowing and spraying the crops, sweeping around the
backyard and planting .
- Pt has hx of
o (-) cigarette smoking
o (-) alcoholic beverage drinker
- Home situation:
o patient lives in a bungalow type of house living with his family
o Room to CR:~2m
o Room to kitchen: ~3m
o Room to main door: ~2m
o Room to living room: ~3m
o Pt. sleeps on a firm mattress and prefers supine or side lying on either side c 1 pillow (~
2”)
o Height of cabinet ~5ft

Family History:
Condition/s Mother Father
HTN (-) (+)
Diabetes (-) (+)
RA (-) (-)
OA (-) (-)
Scoliosis (-) (-)
Heart Disease (-) (-)
Subjective:

c/c: “ Masakit yung kaliwang leeg ko ps 4/10 at kaliwang likod ko c ps 2/10 nahihirapan din akong
lumingon lingon“
Pt’s goal: “ Sana mawala na yung sakit para makapag trabaho na ulit ako”

O:
Vital Signs:
Initial vs
BP 130/80mmHg
HR 88 bpm
SPO2 98%

Significance: for baseline data

Ocular Inspection:
- Ambulatory s AD
- A/C/C
- Endomorph
- (+) Postural deviation (see postural analysis)
(-) Deformity
- (-) atrophy
- (-) swelling
- (-) trophic skin changes
- (-) scars/bruises/wound

PALPATION:
 Thermal Assessment: Normothermic on all exposed body parts
 Normotonic on B UE/LE and back
 (+) Taut bands on B paralumbar area and para thoracic
 (+) tightness of B Hamstring
 (+) mm spasm on B paralumbar area and para thoracic
 (-) tenderness on L paralumbar
 (-) contractures
 (-) edema

SENSORY ASSESSMENT:
Sensory:
Dermatomal/Peripheral
Device used: pin for pain, brush for light touch and thumb for deep pressure
Findings:Pt has intact sensation (100%) on B UE/LE
Sig: for baseline purposes

DTR:
 ® (L)
Legend: 0 areflexia
++ ++ + hyporeflexia
++ normoreflexia
++ ++ +++ hyperreflexia
++++ clonus
++ ++
++ ++

++ ++

Findings: Normoreflexive on (B) UE/LE

Sig: Intact Reflex Arc

All major joints on B UE/LE were grossly assessed actively and passively and are WNL and Normal
end-feel except for:

Motion Right Left NROM Difference End-

feel
AROM PROM
AROM PROM AROM PROM R L R L
Hip flexion 0o-75 o 0o- 80 o 0o- 50 o 0o- 65o 0o-120o 45 o 70 0 40 55 0 empty

Hip extension 0o-38o 0o-45o 0o-37o 0o-49o 0o-60o 220 230 150 110 empty

Findings: ↓ ROM on R/L Hip flexion/extension

Significance: LOM on R/L Hip flexion/extension d/t tightness

MMT: All major (m) groups of UE/LE and neck are assessed using break test and are grossly grade
5/5 except the ff:
Muscle Group Grade
R L
Hip flexors 5/5 4/5
Hip extensors 5/5 4/5
Findings: (m) weakness on L hip flexors/ extensors
Significance: decrease (m) strength on L hip flexors/ extensors d/t immobilization.

SPECIAL TEST:
PROCEDURE POSITIVE SIGN RESULT Significance
SLR 5 Pt is in supine , PT Centralize pain (-) R/o HNP
passively flex the on the back
hip c the knee
extended the
 dorsiflexed the foot
Prone Knee Bend Pt is in prone Pain in the (-) To r/o
Test position ,the anterior thigh tight/strained
examiner passively quadriceps
flexes the patient's muscle or
knee to end range neural tension
and maintains it of the femoral
there for 45 nerve
seconds. The hip Pain on the To r/o lumbar
should not be unilateral lumbar radiculopathy
rotated. area, buttock, or of L2-L3 nerve
posterior thigh roots.
SLR 5 Pt is in supine , PT Centralize pain (-) T/C HNP
passively flex the on the back
hip c the knee
extended the
dorsiflexed the foot
Prone Knee Bend Pt is in prone Pain in the (-) To r/o
Test position ,the anterior thigh tight/strained
examiner passively quadriceps
flexes the patient's muscle or
knee to end range neural tension
and maintains it of the femoral
there for 45 nerve
seconds. The hip Pain on the To r/o lumbar
should not be unilateral lumbar radiculopathy
rotated. area, buttock, or of L2-L3 nerve
posterior thigh roots.

Postural Analysis:

Postural landmarks are assessed in anterior/posterior and lateral views in a sitting position and are
found to be in normal alignment, except for:

Landmark Anterior/Posterior Lateral

Head Midline Slightly forward
Shoulder Sh leveled Rounded shoulder
Thoracic Leveled N Kyphotic Curve
Lumbar N Kyphotic Curve Slight inc in lordotic
curve
Pelvis Leveled Ant. Pelvic tilt
Hip Leveled Neutral
Knee Leveled Neutral
Ankle Leveled Neutral
Foot Leveled Neutral

Findings: (+) postural deviation on A/P and Lateral view such slight forward head posture and slight
increase in lordotic curve
Sig:: (+) postural deviation due to compensatory posture
ADL analysis

Pt is independent in all aspects of ADLs such as self care, bed mobility and transfer.

A:
PT Impression:
- A y/o male that has been diagnosed of having
pt has minimum difficulty in rotating his head, c/o of intermittent, localized dull aching pain on L
paracervical area c ps 4/10, L lower back c ps 2/10 and difficulty in rotating his head. further
manifested by LOM on hip flexion, Taut bands B para lumbar and B parathoracic , tightness of B
Hamstring , mm spasm on B paralumbar area and para thoracic tenderness on L paralumbar and postural
Rehab potential: Pt. has excellent prognosis as to rehab since patient is cooperative and
motivated and made very good progress and responded well c previous PT Tx

Problem List:
1. Intermittent, localized dull aching pain on L paracervical area c ps 4/10, L lower back c ps 2/10
2. LOM on R/L Hip flexion/extension
3. decrease (m) strength on L hip flexors/ extensors
4. postural deviation
5. mm spasm on B paralumbar area and para thoracic
6. Tightness on of Hamstring
7. Taut bands on B para lumbar and B parathoracic
8. gr 1 tenderness on tenderness on L paralumbar

LTG(3x/wk for 12wks)

1. pt. will report an eliminated dull aching pain on, L lower back
2. Pt will be able to eliminate tightness manifested by NROM on hip flexion
3. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics

STG(3x/wk for 6wks)

1. Pt will report a decrease in pain by 2 increments in PS from 2/10 to 1/10 on , L lower back
2. Pt will demonstate a decrease ms tightness manifested by an increase in ROM by 100
increments towards (L/R) hip flexio
3. Pt will present an eliminated mm spasm on B paralumbar area and para thoracic ,Tightness on
of Hamstring, Taut bands on B para lumbar and B parathoracic, gr 1 tenderness on tenderness on
L paralumbar

P:

PT Mx
1. HMPX 15’ on B paralumbar, parathoracic
2. US X 1.25 w/cm2 on B paralumbarand para thoracic
3. Effleurage  MRT
4. Gentle stretching on B hamstring, piriformis and gluteus
5. Pt. education on proper body mechanics and proper posture to avoid complications and/or
further injury

Prepared By:

Gurtiza Joanna Eden

Lorma Colleges PT Intern ‘18