Demographics:

Name: Antonio Talorong Admitting Physician: None

Age: 43 years old Attending Physician: Dr. R. Woo
Sex: Male Referring Physician: Dr. D. Gulapa
Address: Eroreco Subd. Bacolod Rehabilitation Physician: Dr. D Dy
Birthdate: August 11, 1975 Reason for referral: Neck Pain
Occupation: Construction Worker Medical Diagnosis: Torticollis
Civil Status: Married Date of IE: March 26, 2019
Religion: Roman Catholic
Nationality: Filipino
Handedness: Right

S/: All information was taken from the pt. c 100% reliability
C/C: Pt. c/o intermittent aching pain on L post. neck area aggravated by lifting up et rotating to the R
side of his neck et relieved by tucking his chin on the L side.
cc: Pt has difficulty on reaching, head movements et walking 2° to pain on his post. L neck.

HPI: Present condition started 4 months ago, (specific date unrecalled) when Pt. felt an aching pain on
his L Neck graded 7/10 on P.S. (0 = no pain, 5 = moderate, 10 = severe) Pt. used Pau D’arco to relieve
the pain temporarily, et takes Alaxan if the pain cannot be taken away by the topical agent. Patient can
perform overhead activities but not fully due to the aggravating pain as he continues the ROM to the
end range. Pt has been working as a construction worker for three years et has history of stiff neck for
the last three years. Pt decided to consult a doctor because the pain is worsening overtime. He went to
The District Hospital on March 24, 2019, was attended by doctor Woo, a General Medicine Practitioner.
After few assessments, pt was instructed to go to Dr. D. Gulapa, a Neurosurgeon. Dr. Gulapa assessed
the pt’s neck mm and movements. Dr. Gulapa suspected that the pt’s condition is not just a musculo-
skeletal of origin et wanted to be sure so he instructed the pt to have an MRI et CT scan of his neck and
findings showed that pt had lesion on his peripheral CN 11. Pt was reffered to Dr. D. Dy for
rehabilitation.
Prev.Intervention:
Intervention Purpose

Pau D’ Arco To alleviate e pain Every morning et night

Alaxan To alleviate e pain 500 mg every time pain occurs

Ancillary Procedures:
Procedure Result

MRI (-) (+) lesion on peripheral CN 11

CT-Scan (-) (-)

Fam Hx:
Disease Paternal Maternal Patient

Htn (-) (-) (-)

OA/RA (+) (-) (+)

Diabetes (-) (-) (-)

CA (-) (-) (-)

CVA (-) (-) (-)

Significance: Pt. acquired OA from paternal side 20 hereditary predisposition.

Findings: (+) RA on paternal side on Pt.

Functional Hx: Pt. is indep in all aspects of ADL’s as to ADEPTC.

Personal and Social Hx:

Frequency

Coffee (+) Twice/day

Milk (+) Once/day

Alcoholic Drinks (-)

Smoking (-)

Soda (-)

Home Situation: Pt. currently lives in St Vincent’s a bungalow house compound with cemented flooring.

Type of house One-story house

Type of flooring cemented

Stairs (-)

Doorknob type
Bed room to Garden ~ 15 steps

Bed room to entertainment room ~ 20 steps

Bed room to Chapel ~ 30 steps

Dining area to bedroom ~40 steps

Bedroom to CR ~20 steps

Functional History:
Pt lives in a Home Care Facility c four other Male Geriatrics in one cottage.
4:00-4:30 am Pt wakes up et listens to his radio

4:31-5:00 am Pt drinks coffee et eats beakfast

5:30-6:00 Pt takes a bath

6:30-11:00 Pt goes to work

11:00-12:00 nn Pt eats lunch

1:00-4:00pm Pt goes back to work

5:30-7:00 pm Pt goes home

7:30-8:00 pm Pt eats dinner

9:00pm Pt goes to bed

Pt Goal: Pt. states that “gusto ko lang magiho tadlong ang akon ngaulo kag maka ubra nga waay
gasakit ang akon liog.”

/O/: Pt. is CCC as to ppt x3

OI: Pt. is Ectomorphic
Pt. has mass on L. post neck
Pt. can ambulate without assistive devices with no difficulty
 (-) swelling L post neck  (-) attachments
 (-) mm atrophy  (-) gait deviation
 (-) wounds and scars  (+) postural deviation
V/S:
a tx During tx p tx Method Location Position
BP 120/60mmHg 120/70mmHg 110/50mmHg auscultation (L) arm sitting
PR 65 bpm 70 bpm 75 bpm palpation (L) radial sitting
artery
RR 12 cpm 16 cpm 15 cpm abdominal abdomen sitting
Temp. 36.5 C 36.5 C 36.5 C Tympanic (L) ear sitting
O2 sat. 100% 100% 100% Pulse (L) index sitting
oximeter Finger
Significance: No significance noted.

Palpations: Pt. is normotonic and normothermic on all exposed body parts; (-) edema, (-) mm. guarding,
(-) mm. spasm, except:
(+) hypothermia L Knee Grade 1

(+) tenderness Post. L neck Grade 2

Significance: (+) Hypothermia on L Knee 20 to degeneration of jt.et (+) mm tenderness on post. L neck 2°
to pain.

Sensation: Pt. has 100% intact sensation as to pain, light touch, and pressure (pain – pin, light touch –
brush, pressure – thumb)

Significance: Pt. has complete intact sensation.

DTR:
 0 – areflexia
 I – hyporeflexia
 II – normoreflexia
 III – hyperreflexia
 IV - clonus

Significance: Pt has normal tendon reflexes in all deep tendon areas.

ROM: All mm. joints of both UE et LE actively and passively assessed and are WNL, except:
Joint Normal AROM Diff. PROM Diff. Endfeel
Cervical 50° 50-52° 3° 55° 0° Firm
Flexors
Cervical 60° 0-5° 55° 15° 45° Empty
Extensors
L Lateral 45° 35-39° 6° 35° 10° Empty
Flexors
R Lateral 45° 0-35° 10° 38° 7° Empty
Flexors
L Cervical 80° 23° 57° 25° 55° Empty
Rotators
R Cervical 80° 15° 65° 17° 63° Empty
Rotators
L Shoulder 0-180° 0-151° 29° 0-156° 24° Firm
Abductors
R Shoulder 0-180° 0-144° 36° 0-152° 28° Firm
Abductors
L Shoulder 0-180° 0-150° 30° 0-158° 22° Firm
Flexors
R Shoulder 0-180° 0-144° 36° 0-150° 30° Firm
Flexors
AL Shoulder 0-60° 0-52° 8° 0-55° 5° Firm
Extensors
R Shoulder 0-60° 0-49° 11° 0-53° 7° Firm
Extensors
L Elbow 0-145° 0-132° 13° 0-137° 7° Firm
Flexors
R Elbow 0-145° 0-138° 7° 0-140° 5° Firm
Flexors
Significance: Pt has ↓ROM on all planes of bilat. UE 2° to weakness,↑ Cervical √ et ↓ ROM of the
cervical ∕,R et L lat. √ et R et L rotators 2° pain.

MMT: All mm. group of both UE et LE are grossly assessed et are graded as 5/5, except:
MM Group Grade
Cervical Flexors 3-/5
Cervical Extensors 3-/5
L Lateral Flexors 3-/5
R Lateral Flexors 3-/5
L Cervical Rotators 3-/5
R Cervical Rotators 3-/5
L Shoulder Abductors 3-/5
R Shoulder Abductors 3-/5
L Shoulder Flexors 3-/5
R Shoulder Flexors 3-/5
L Shoulder Extensors 3-/5
R Shoulder Extensors 3-/5
L Elbow Flexors 3-/5
R Elbow Flexors 3-/5
Significance: mm strength on cervical flexion, cervical extension, L lateral neck flexion, R lateral neck
flexion, L cervical rotation, R cervical rotation, L shoulder abduction, R shoulder abduction, L shoulder
flexion, R shoulder flexion, L shoulder extension, R shoulder extension, L elbow flexion et R elbow flexion
20 to mm weakness.

Special Test:
Test Indication

(+) apley’s scratch test To increase rom for overhead activities

(-) Forward bending test Test for spinal deformities ( scoliosis)
(-) spurling test Test for nerve root pathology

Significance: Pt has ↓ ROM on all planes of bilat. UE 2° mm weakness, manifesting (+) apley’s scratch
test et
Postural Analysis:
Area AP L
Head and Neck Not aligned deviated
Shoulders R higher Aligned
Elbow level Aligned
Hips level Aligned
Knee Genu recurvatum Slightly forward
Ankle and Foot level Flat footed
Significance: Pt. has genu recurvatum and pes planus (flat foot).

MBT:
Upper Extremities Lower Extremities
Right Reference: Left Difference Right Reference: Left Difference
Medial Medial
Epicondyle Condyle
30cm 20cm 30cm 0cm 40cm 20cm 40cm 0 cm
above above
28cm 15cm 28cm 0cm 38cm 15cm 37cm 1cm
above above
26cm 10cm 26cm 0cm 36cm 10cm 36cm 0cm
above above
24cm 5cm 24cm 0cm 32cm 5cm above 32cm 0cm
above
20cm 5cm below 21cm 1cm 28cm 5cm below 27cm 1cm
18cm 10cm 18cm 0cm 25cm 10cm 25cm 0cm
below below
15cm 15cm 16cm 1cm 22cm 15cm 21cm 1cm
below below
Significance: No significance noted

LLD:
LLD Left Right
True 32” 33”
Apparent 37” 37”
Significance: No significance noted.

LGM:
Part Trial 1 Trial 2 Trial 3 Average
R foot 18cm 18cm 18cm 18cm
L foot 18cm 18cm 18cm 18cm
Difference 0cm
R hand 8cm 8cm 8cm 8cm
L hand 8cm 8cm 8cm 8cm
Difference 0cm
Significance: No significance noted.

Balance and Tolerance:

Position Balance Tolerance
Sitting N N
Standing N N
Walking N N
Significance:No significance.

Legend:
Grading for balance
N- Able to maintain balance without support. Accepts maximal challenge and can shift weight in all
direction
G- Able to balance without support. Accepts moderate challenge and can shift weight although
limitations are evident.
F- Able to maintain without support, cannot tolerate challenge and cannot maintain balance while
shifting weight.
P- Requires support to maintain balance
Grading for tolerance
N- >60 mins. Or 15-30 mins
G-30-45 mins or 10-15 mins
F- 15-30 mins or 5-10 mins
P- <15 mins or <5 mins

FIM:
Self-care A. Eating 7
B. Grooming 7
C. Bathing 7
D. Dressing - upper 7
E. Dressing - lower 7
F. Toileting 7
Sphincter control G. Bowel 7
H. Bladder 7
Transfers I. Bed, chair, wheelchair 7
J. Toilet 7
K. Tub, shower 7
Locomotion L. Walk 7
M. Stairs 7
Communication N. Comprehension 7
O. Expression 7
Social cognition P. Social interaction 7
Q. Problem solving 7
R. Memory 7
Total Score 126
Significance: Pt. is indep. In all functional activites.

FIM Levels:
No Helper – Independence
7 – Complete Indep (Timely and Safely)
6 – Modified Indep (Device)

Helper – Modified Dependence

5 – Supervision (Subject=100%)
4 – Minimal Assistance (Subject=75%)
3 – Moderate Assistance (Subject=50% or more)
Helper – Complete Dependence
2 – Max. Assistance (Subject=25% or more)
1 – Total Assistance or not Testable (Subject= <25%)

/A/:
Practice Pattern: Musculoskeletal (Pattern 4B): Impaired Posture
PT Impression: PT Impression: Pt. is a y/o Male pt c c/o intermittent aching pain on L post. neck
aggravated by lifting up et rotating to the side of his neck et relieved by tucking his chin, has difficulty on
reaching, head movements 2° to pain on his L neck. Has acquired OA from paternal side 20 hereditary
predisposition, has mass on L. post neck, can ambulate without assistive devices with no difficulty. Is
normotonic and normothermic on all exposed body parts; (-) edema, (-) mm. guarding, (-) mm. spasm,
except (+) mm tenderness on L neck graded 2 on Tenderness Scale, has ↓ROM on all planes of bilat.
UE 2° to weakness,↑ Cervical √ et ↓ ROM of the cervical ∕,R et L lat. √ et R et L rotators 2° pain. Pt has
↓ ROM on all planes of bilat. UE 2° mm weakness, manifesting (+) apley’s scratch test et (-) forward
bending test, manifests (-) heel strike and toe off on his bilat. limb et.↓ in all swing phases on his bilat.
limb.2° genu recurvatum deformity of B LE . Pt. is indep. In all functional activites.

PT Prognosis:
Positive Factors:
1. (+) Cooperative – pt. is highly coherent and participative in treatment process.
Negative Factors:
1. (+) Age – Pt. Musculature and Posture recovery rate isn’t high due to the pt.’s old age
2. Pt has been abandoned by his significant others, et lacks support.
3. Pt has no financial support.

Rehab Potential: Pt. has a good rehab potential because of his cooperation to the treatment and
eagerness to relieve the pain. Pt. can be referred to an orthopedic doctor for further medication and
treatment. Pt. doesn’t need any assistance for ambulatory assistance.
Problem List:

1. (+) Pain on L Neck

2.(+) postural deviation
4. (+) LOM on B UE et cervical lat √, ∕ et rotators
5. has difficulty in reaching overhead activities

Long Term Goal: Pt. will feel pain free range of motion of upon doing overhead activities et moves his
neck c no pain.
Short Term Goal:
1. Pt. will manifest pain on L post. neck from 5/10 – 3/10 p 3 tx sessions.
2. Pt. will manifest ↑ ROM on cervical area p 7 tx sessions.
3. Pt. will manifest MMT grade on L post. neck and UE ROM from 3-/5 – 3/5 p 3 tx sess
4. Pt will manifest ↑ functional head movn’t on B UE p 10 PTx sessions

PT Summary: Pt. completed and tolerated all PTM without any untoward incident happened during PT
tx session.

/P/: Pt. will be seen as an OP @ Grey-Sloan Memorial Hospital p 3 months c the following PTM:
1. TENS on L neck for 15 mins. to decrease pain et tissue extensibilty.
2. Callet exercises to ↑ cervical ROM 5 reps, 5 sets.
3. PNF D2 flexion on B UE to develop UE reaching activities 10 reps, 5 sets (progression c thera
bands/ dumbells)
4. Dynamic Stretching exercises of e scapular mm to ↑ ROM et exercise scapular mm for
unleveled shldrs
 5. Isometric exercises on B UE to ↑ mm strength 8 reps, 4 sets

Suggested PT Mgx:
 Scapular exercises to balance mm strength of the shoulder
 Alternate Protractor et retractor mm stretch to strengthen the retractor mm.

HEP:
 Head and neck exercises to avaoid aggravating the deformity
 Resisted reaching movement to strengthen the scapular et shldr mm.

Recommendations:
 Pt must wear neck brace ( cervical orthosis) to maintain the cervical area in neutral position et
to protect et limit possible deformities.
 Pt must stay active in performing daily activities to maintain good Cardio Vascular condition

xxx Nothing Follows xxx

Kevin Magallanes
BSPT 4C