Saint Louis Hospital of the Sacred

Department of Physicall Medicine and Rehabilitation

Baguio City
PT INITIAL EVALUATION

General Information
Patient’s Name : Y.P Religion : Roman Catholic
Age : 38y/o Referring unit : OPD
Gender : Female Rehab Dr : Andrew Bautista MD. FRARM
Address : Irisan, Baguio City Date of Referral : April 3, 2018
Civil Status : Married Date of IE : April 3, 2018
Handedness : Right-handed Diagnosis :Chronic (B) C6 C7 Cervical
Occupation : Housewife Radiculopathy

c/c: Px c/o constant dull aching pain on (B) neck and upper back (R)> c ps 5/10 (L) c ps 3/10 c radiating pain
from occiput to shoulder c PS 7/10 .

HPI:
Present condition started ~1 yr ago when pt. felt when patient felt a constant dull aching pain on (B)
neck and upper back (R)> c ps 5/10 (L) c ps 3/10 c radiating pain from occiput to head c PS 7/10 every p
washing clothes. Patient stated that she underwent masseur 2x a week and felt a relaxation and a
decrease of pain from ps 7/10 to 5/10 on B) neck and upper back.
At ~ 2 mos PTIE Patient went to SLU Sacred Heart hospital ER to consult medical advice. Patient was
attended by Dr.(unrecalled) no ancillary procedure was done, and was only given medication(unrecalled)
for muscle relaxant. Patient stated that a decrease of heaviness on (B) neck and upper back was noted.
~ 1wk PTIE patient can no longer tolerate the pain and bothers her during sleeping patient
went to SLU Sacred Heart hospital ER and was referred to SLU Sacred Heart hospital PT Rehab. Patient was
attended by DR. Bautista, no ancillary procedure was done, and patient was then diagnosed of having
Chronic (B) C6 C7 Cervical Radiculopathy and was given medication (see medication). Patient recommended
him to undergo PT Rehab to address his complain.

Ancillary Procedures: no AP was done

Past Medical and Surgical History:

(+) Hospitalization d/t surgery on breast (2016) at SLU Sacred Heart hospital
(-) HTN
(-) Stroke
(-) Accidents
(-) Fall
(-) Trauma
(-) Heart disease
 (-) Diabetes
(-) Scoliosis

Medications:
Medication/s (Brand) Dosage/Route of Indication
Administration
dolfenal 500mg 1x a day Pain relief
Myonal 50mg 2x a day Pain relief

Personal, Social and Living Environment:

Sedentary lifestyle
Pt has hx of
(-) cigarette smoking
(-) alcoholic beverage drinker
Home situation:
patient lives in a 3-storey house with her family
Pt. works as a housewife and does all the household chores
Pt. wash clothes 2x a week using a washing machine
Pt. carries ~5kg of pail
Height of the clothesline: 5ft
Pt sleeps on a firm mattress and prefers on side lying on L side c 1 pillow (~ 2”)

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

Subjective:

c/c: “ masakit yung leeg ko at upper back ko hanggang shoulder”

Pt’s goal: To do household chores pain free

O:
Vital Signs:
Initial vs After PT Tx
BP 110/80mmHg 120/90 mmHg
HR 82 bpm 84 bpm
SPO2 98% 97%
 Significance: for baseline data

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

Palpations:
Normothermic on all exposed areas
Normotonic on all 4’s
(+) muscle spasm on B splenus capitis, upper trapz, levator scapulae
(+) taut band on B B splenus capitis , upper trapz
(+) gr 1 tenderness on B Upper trapz and rhomboids
(+) Nodules on B rhomboids
(-) ms guarding

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

Deep Tendon Reflexes:

Legend:
0 – areflexia
+ - hyporeflexia
++ - normoreflexia
+++ - hyperflexia
++++ - clonus

Findings: Normoreflexive on all 4’s

Significance: Intact reflex arc

ROM:
 All major joints of B UE/LE c cervical jts are grossly assessed actively and passively done and are found to
be WNL, pain free and c normal endfeels except:
Motion Active Normal Difference End-
feel
L R Active
Cervical L R
0 0 0 0
Lateral flexion 0-38 0-40 0-45 7 50 Tight
0 0 0 0
Rotation 0-50 WNL 0-60 10 0 Tight

Findings: LOM on Lateral fexion and rotation

Sig: LOM 2o pain and tightness

MMT:
Findings: All major (m) groups of UE/LE and neck are assessed using break test and are grossly grade 5/5
except
Sig: baseline data

Special Test:

ST Procedure (+) sign Significance

ULTT 1 Shoulder girdle Radiating pain or (-) ULTT 1 /To r/o
depression Shoulder tingling sensation in radiculopathy
joint abduction any stage of movement
Forearm supination on the test side
Wrist and finger
extension Shoulder
joint laterally rotated
Elbow extension
ULTT 2 Shoulder girdle Radiating pain or (-) ULTT 2/ To r/o
depression Elbow tingling sensation in radiculopathy
extension Lateral any stage of movement
rotation of the whole on the test side
arm Wrist, finger and
thumb extension
ULTT 3 Wrist and finger Radiating pain or (-) ULTT 3/ To r/o
extension Forearm tingling sensation in radiculopathy
pronation Elbow any stage of movement
flexion Shoulder girdle on the test side
depression Shoulder
lateral rotation
Shoulder abduction
ULTT 4 Patient is supine , with Radiating pain or (-) ULTT 4 /To r/o
their side being tested tingling sensation in radiculopathy
at the edge of the table any stage of movement
Examiner applies a on the test side
depressive force to the
patient’s affected
shoulder
With examiner’s other
hand, hold the
patient’s wrist and
Abduct their affected
humerus to 90°
Examiner slowly flexes
patient’s elbow, then
supinate their forearm
Examiner slowly extend
patient’s wrist and
fingers and deviate the
wrist to the radial side.

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 is not aligned
Thoracic N Kyphotic Curve N Kyphotic Curve
Lumbar N Lordotic curve N Lordotic curve
Pelvis Leveled Leveled
Hip Leveled Leveled
Knee Leveled Leveled
Ankle Leveled Leveled
Foot Leveled Leveled

Findings: (+) postural deviation on A/P and Lateral view c light forward head posture
Sig: (+) postural deviation due to habitual posture

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

A:
PT Impression:
1. A 38y/o female c/o constant dull aching pain on (B) neck and upper back (R)> c ps 5/10 (L) c ps 3/10
c radiating pain from occiput to shoulder c PS 7/10 further manifested by LOM on cervical lateral
flexion and rotation, and Muscle spasm on B splenus capitis, upper trapz, levator scapulae, scalene,
 Taut band on B B splenus capitis , upper trapz, Gr 1 tenderness on B Upper trapz and rhomboids,
Nodules on B rhomboids 20 to Chronic (B) C6 C7 Cervical Radiculopathy.

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:
2. Px c/o constant dull aching pain on (B) neck and upper back (R)> c ps 5/10 (L) c ps 3/10 c radiating
pain from occiput to shoulder c PS 7/10 especially p washing chothes.
3. Pt has ↓ AROM on cervical lateral flexion and rotation
4. Postural deviation
5. Muscle spasm on B splenus capitis, upper trapz, levator scapulae, scalene
6. Taut band on B B splenus capitis , upper trapz
7. Gr 1 tenderness on B Upper trapz and rhomboids
8. Nodules on B rhomboids

LTG: TX 3x/wk x 4ks

1. Pt. will be able to perform work activities especially p washing clothes pain free.
2. Pt. will be able to achieve NROM on cervical lateral flexion and rotation
3. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics

STG: Tx 3x/wk x 2 wks

1. Pt. will be able to state decrease pain sx on (B) neck and upper back (R)> c ps 5/10 to 3/10 (L) c ps 3/10
to 1/10.
2. Pt. will exhibit an eliminated m tightness b upper traps, scalenes and levator scapulae, ms spasm B
splenus capitis, upper trapz, levator scapulae, scalene, Taut band on B B splenus capitis , upper trapz
and Gr 1 tenderness on B Upper trapz and rhomboids

Suggested PT Mx:
1. Pt. Education on proper body mechanics and proper posture to improve posture and avoid further strain
2. Kinesiotaping to provide support on B Upper trapz and Cervical muscles extending from acromion
process to neck
3. HEP
a. Self stretching techniques:
On cervical muscles and trapz to reduce tightness x 30 SH x 2 reps

Prepared By:
Gurtiza Joanna Eden
Lorma Colleges PT Intern ‘18