Px Name : Josephina Nepomuceno

Age : 68 years old

Sex : Female
Address: Blk 7 lot 24 Golden City Binan
Civil Status : Married
Citizenship : Filipino

Handedness :
Occupation : None
Religion : Roman Catholic
Date of IE : September 09 2015
Dx :
S : C/C Px complaints of numbness on (B) anterior aspect of the leg
HPI :
Present condition started July 2007 at around 5:00am upon going home from
the bakery. Px get bumped by a car and fell down on the floor. Px was immediately
rushed to Binan Hospital and nurses gave wound care as first aid. After a while px
transferred to Perpetual Hospital on where he underwent surgical stitched and
underwent CT scan ( see ancillary procedure) Px was then transferred to Orthopedic
Hospital Manila. Px leg had been cast and lasted for 1 month before it was
removed and underwent X-Ray. After one month when the operation was done px
referred to PT rehab for about one year but stopped for she thought that shes
condition is already stable.
2 months PTIE px felt numbness on (B) leg so she decided to put liniment but
the pain wasnt subside. A day PTIE px decided to go to City of Binan Main health
Center to seek medical advice and was then referred to Physical Therapist for
further evaluation and treatment.
PHMX
(+) Previous hospitalization (July 2007)
(+)Arthritis
(+)DM
(+)HTN
(-)Cancer
(-)COPD
FMHX
Cancer
COPD
HTN
DM
SHX
Sedentary lifestyle
Non alcoholic beverage drinker
(-) Cigarette smoker

(M)
(+)
(-)
(-)
(-)

(F)
(+)
(-)
(-)
(-)

Px lives in a subdivision, two storey house in the 1 st floor with 5-7 steps from bed
and restroom
Medication Taken:
Drug Name
Amlopidin

Dose
50mg

Frequency
OD

Metformin

50mg

TID

Indication
a medication used to
lower blood
pressure and prevent
chest pain
Metformin is an oral
diabetes medicine t
hat
helps
control
blood sugar levels.

O
VS:
BP : 120/80mmHG
RR:
PR:
T: Afebrile to touch
OI
Ambulatory
Mesomorph
A/C/C
(+) Dislocation on (L) shoulder
(+)Surgical scar on leg
(+)Wound scar on head
(+) Slouch posture
(+) Skin tropihic changes (Dry skin on (B) leg)
(-)Cyanosis
(-)Ptsosis
Palpation
Normothermic on all exposed body parts
Normotonic on all extremities except for (L) shouklder which is hypotinic
(-)Swelling
(-)Edema
(-)Muscle guarding
DTR

Legend
++++ Clonus
Nomoreflexia on (B) UE/LE
+++ Hyperreflexia
affectation on UMNL
++ Normoreflexia
+Hypoflexia
0 Areflexia

Findings :
Significance: No

ROM
All muscles of (B) UE/LE are WNL actively passively done except

(L) Shoulder
flexion
(L) Shoulder
abduction

(A)
0-0

(P)
0-180

(N)
0-180

Difference
(A)
(P)
180
0

0-40

0-180

0-180

140

Findings : Px has LOM on (L) shoulder towards flexion and abduction

Significance : Due to dislocation secondary to muscle weakness
MMT
Muscle Groups
(Cervical Spine) Flexors
Extensors
Rotators
(Trunk) Lat. Flexors
Rotation to
Lat flexion to
Flexors
Extensors
(Shoulder) Flexors
Int rotators
Ext rotators
Abductors
(Elbow) Flexors
Extensors
(Forearm) Supinator
Pronator

0
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

(L)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

End feel
Firm

Firm

Muscle Groups
(R)
(L)
(Wrist) Flexors
4
1
Extensors
4
1
Ulnar Deviators
4
1
Radial Deviators
4
1
(Hip) Flexors
3
3
Extensors
3
3
Abductors
3
3
Int. Rotators
3
3
Ext. Rotators
3
3
Flexors
3
3
(Knee) Flexors
3
3
Extensors
3
3
(Ankle) Dorsal Flexors
3
3
Plantar flexors
3
3
Invertors
3
3
Evertors
3
3
Findings : Px has muscle weakness on (B) LE with the grade of 3/5; UE with the
grade of 4/4; and (L)UE with the grade of 1/5
Significance : Due to dislocation of the shoulder and age.
Sensory Evaluation
STD used pin for pain, brush for light touch, and thumb for pressure
Superficial
Pain
Temperature
Light touch
Pressure

UE
(R)
(L)
100%
100%
100%
100%
100%
100%
100%
100%

LE
(R)
(L)
60%
100%
100%
100%
60%
100%
100%
100%

Trunk
(R)
(L)
100%
100%
100%
100%
100%
100%
100%
100%

Special Test
(-) Homans sign
For Deep Vein Thrombosis
FIM
Legend
7= Independent
6=Independent with equipment/modified environment

Face
(R)
(L)
100%
100%
100%
100%
100%
100%
100%
100%

5=Independent with set-up distant supervision

4=Minimal assistance/Intermittent supervision/Contact guarding (patients performs
755 or better)
3=Moderate assistance
2=Maximal assistance
1-Dependent assistance
0=Activity does not occur
ACTIVITIES OF DAILY LIVING
Eating
Grooming
Bathing
UE dressing
LE dressing
Toileting
Bladder management
Bowel management
Bed to chair transfer
Toilet transfer
Shower transfer
Locomotion
Stairs
Cognitive comprehension
Expressions
Social interaction
Problem solving
Memory

7
7
7
5
7
7
7
7
7
7
7
7
5
7
7
7
7
7

Findings : Px can perform independent in all aspects of ADLS except for dressing in
UE and stepping at stairs which is independent with distant supervision.
Significance : Due to muscle weakness at age.
PT impression:
Px was medically diagnosed of ______________ which has muscle weakness on (B) LE
with the grade of 3/5; UE with the grade of 4/4; and (L)UE with the grade of 1/5
who complaints of numbness of her (B) LE. Px has independent in all aspect of ADL
except for Dressing in UE and steeping on upstairs who needs distant supervision.
Problem list
1. Muscle weakness on (B) LE with the grade of 3/5; UE with the grade of 4/4;
and (L)UE with the grade of 1/5
2. LOM on (L) shoulder towards flexion and abduction
3. Difficulty in aspect of ADL as to dressing in UE and stepping upstairs
4. Numbness on (B) leg
STG
1. To increase muscle strength on on (B) LE with the grade of 3/5 from 4/5; UE
with the grade of 4/5 to 5/5; and (L)UE with the grade of 1/5 to 2/5

2. To increase ROM on (L) shoulder

3. To achieve Functional independence from distant supervision to independent
with equipment as to dressing in UE and stepping upstairs.
LTG
1. To achieve near normal muscle strength on (B) UE/LE
2. To achieve near normal ROM on (L) shoulder
3. To achieve total independent in ADL as to dressing in UE and stepping on
stairs.
Suggested PT management
1. Tens on (B) LE X 10
2. US X1.5w/cm2 on (B) Knees
3. AROMES on (B) LE X10reps X 2sets
4. Effleurage massage X5mins
Home Instruction
Put sling on dislocated arm

Christine B. Balasbas
UPHS-GMA PT Intern 2016