INITIAL EVALUATION

PERSONAL DATA: Date of IE: 11-Apr-2019

Name: 1LT Marnel Collado Handedness: R
Age/Sex: 50/♂ Date of Consultation: unrecalled
Address: Babag II, Lapu-Lapu City Date of Admission: OP
Tel#/Cell#: +639258166730 Bed#/Rm#: OP
DOB: 28-May-1986 Date of Referral: unrecalled
Nationality: Filipino Referring MD: Col. Getulio J Santos Jr, MC (Ret)
Civil Status: Married Physiatrist: Direct
Occupation: Philippine Military Officer Dx: Cervivcal Radiculopathy
Religion: Roman Catholic
Informant: (Pt. & pt.’s wife c̄ 100% reliability)
C/C: Pt. c/o radiating pain from the R shoulder down to the R hand rated at 10/10 on NPRS (0=no pain, 5=mod pain,
10=severe pain); is relieved when pt. bends his head forward; aggravated when Pt. extends his head backward.
HPI: Present condition started last Jan-2019 upon waking up in the morning, pt. suddenly felt pain on R shoulder which
radiated down towards the R hand. Pt. applied “salonpas” on his R shoulder to alleviate the pain; on the a.m of 26-Feb-
2019, Pt. consulted physician @ Mactan Airbase Hospital (unrecalled) who referred pt. to Dr. Yongco @ Perpetual Succour
Hospital who ordered the MRI on 09-Mar-2019; results showed a cervical radiculopathy. Pt. was then referred by Dr. Yongco
for PT rehab session @ PSH for 8 sessions. Pt. then decided to continue PT rehab sessions @ Camp Lapu-Lapu Station
Hospital & consulted Col. Getulio J Santos Jr, MC (Ret). Started PT Rx @ CLSH on 28-Mar-2019.
Med/Surg Hx: None
FMHx: (General screening of parental health hx, tabled with significance. Max of 7.)
Maternal Paternal
HTN (+) (-)
DM (-) (-)
Pulmonary problems (-) (-)
CA (-) (-)
CVA (-) (-)
Cardiac problems (-) (-)
OA/RA (-) (-)
Personal Hx:
 Social Hx: : Pt. has no religious or cultural beliefs that may hinder quality care; lives c̄ (W) & 2 children. (W) is able
to assist. pt. throughout the day.
 Employment/Work Status: Pt. is a full-time military officer; works from 0800H-1700H qd inside the office; is seated
most of the time.
 General Health Status: pt. rates his health as good; has not experienced any major life changes in past yr.
 Social Health Habits: Pt. denies smoking cigarettes but admits to drinking ~1-2 bottles of alcoholic beverages
occasionally; wakes up at 0500H qd to jog for 30 min., does push-ups, sit-ups & planking for another 30 mins. as
ex.
Living Environment
• Pt. lives in bungalowc̄tiled flooring
• Pt.’s room is on the ground floor
• Cabinets & light switch hts. are of standard ht.

Ancillary Procedures:
Procedure, Area Date, Hospital Result
MRI 09-Mar-2019, PSH Cervical Radiculopathy
Medications:
Source Name Dosage/Frequency Indications Compliance
Pt. Myonal 50 mg, TID Ms. relaxant Pt. is compliant
Pt. Pregabalin 150 mg, TID pain Pt. is compliant
Prior Level of Function: Pt. was able to lift heavy loads/objectss̄pain/discomfort
Current Level of Function: : Pt. can still perform all basic ADLs indeps̄assist., although refrains from lifting heavy loads
for it may aggravate sx.
Goals & Attitude toward Therapy:
• Pt. wants total relief of pain R shoulder to perform lifting activitiess̄any pain/discomfort
• Pt. Is cooperative during Rx session & is determined to recover
O:
OI:
 amb.s̄ assist. device
 mesmorphic
 (+) postural deviation
 (-) attachments
 (-) scars

SYSTEMS REVIEW:
Cardiopulmonary System: Impaired or Unimpaired.
V.S. a Rx p Rx Location, method, position
BP (mmHg) 120/70 120/70 L brachial artery, auscultory, sitting
PR (bpm) 78 77 L brachial artery, palpatory, sitting
SpO2 (%) 98 98 R index finger, sitting
Integumentary System: Unimpaired
 Skin Pliability: Unimpaired
 Skin Color: Unimpaired
 Skin Texture: Unimpaired
Musculoskeletal System:
 Gross symmetry: Unimpaired
 Gross ROM: Impaired
 Gross Strength: Unimpaired
Neuromuscular System:
 Gait: Unimpaired
 Locomotion: Unimpaired
 Balance: Unimpaired
 Motor function: Unimpaired
Communication: Unimpaired; pt.’s communication is age-appropriate
Affect: Emotional & behavioral responses are unimpaired
Cognition: Pt is alert; oriented x 3 as to PPT
Learning Barriers: Pt. can speak & understand Visayan language & understands best through conversing in bisaya.
Learning Style: Pt. learns best when given instructions verbally; prefers to be demonstrated on how the ex. is done c̄
verbal & tactile cues; also asks questions about the rationale for each ex.
Education Needs: HEP, proper body mechanics, safety, aggravating positions, proper posture
TEST & MEASURES:
Sensory Assessment: Sensory testing device used: small nylon brush or cotton for light touch, sharp & dull ends of a
neurohammer for superficial pain and deep pressure respectively.
Superficial Sensory
Light touch Pain Pressure Light touch Pain Pressure
Dermatome
L L L R R R
2 2 2 C5 2 2 2
2 2 2 C6 2 2 2
2 2 2 L3 2 2 2
2 2 2 L4 2 2 2
2 2 2 L5 2 2 2
Legend: 2-Normal, 1-Impaired, 0-Abesent
Significance: Pt. has 100% intact sensation as to pain, pressure, & light touch.
ROM: All major jts. in the body were grossly assessed, actively & passively, & found to be WNL c̄ normal end-feel except:
Joint N° AROM° DIFF° PROM° DIFF° END-FEEL
Cervical flex 0-90 0-60 30 0-70 20 Firm
Cervical ext 0-70 0-50 20 0-50 20 Empty
R Cervical rot. 0-90 0-70 20 0-80 10 Empty
L Cervical rot. 0-90 0-60 30 0-70 20 Empty
Legend:
Normal End-Feels Abnormal End-Feels
End- End-Feel Structure
Structure Soft Feels boggy, with fluid shift
Feel
Soft tissue Firm Occurs sooner or later than normal
Soft Hard Grating or bony block is felt
approximation
Firm Muscular stretch No real end because pain prevents reaching end of
Empty ROM. No resistance is felt except. for pt.’s protective
Capsular stretch ms. splinting/spasm
Ligamentous stretch
Bone contracting
Hard bone
 Physical Rehabilitation 6th Edition by O’Sullivan & Schmitz

Significance: Pt. has ↓ ROM on cervical flexion due to tightness; extension & B cervical rotation due to pain 2° Cervical
Radiculopathy.
MMT: All major ms. groups of the body were grossly assessed & graded 5/5.
Significance: Pt. has no significant ↓ in ms. str.
Physical Rehabilitation 6th Edition by O’Sullivan & Schmitz
Special Test:
Special Test Procedure Positive reaction (+) reaction Result
Spurling’s test The examiner turns pain arising in the nerve root pain (+)
the patient's head to neck radiates in the
the affected side direction of the
while extending and corresponding
applying downward dermatome
pressure to the top ipsilaterally.
of the patient's head.
Adson’s test Palpate the radial A positive test is a presence of Thoracic (-)
pulse on the affected decrease in pulse Outlet syndrome
side with the elbow vigor from the starting
fully extended. Have position to the final
the patient rotate position.
their head to the side
being tested and
extend the neck.
Next, abduct, extend,
and laterally rotate
the shoulder. From
this position, have the
patient take a deep
breath and hold.
Assess the pulse
response.

Orthopedic Physical Assessment 5th Edition by David J. Magee

Significance: Pt. is positive in Spurling’s Test indicative of (+) nerve root pain.
ADL Analysis
Quick- DASH
1. open a tight or new jar 1
2. do heavy household chores 1
3. carry a shopping bag or brief case 2
4. wash your back 3
5. use a knife to cut food. 1
6. Recreational activities in which you take some force or impact through your arm, shoulder or hand. 2
7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal 3
social activities with family, friends, neighbors or groups?
8. During the past week, were you limited in your work or other regular daily activities as a result of your 3
arm, shoulder or hand problem?
9. Arm, shoulder, or hand pain 4
10. Tingling in your arm, shoulder or hand 4
11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, 3
shoulder or hand?
Legend: severity & functional scale: 1= no difficulty/not limted; 2=mild difficulty/slightly limited; 3= moderate difficulty/moderately limited; 4= severe
difficulty/very limited; 5= extremely/unable
Posture: Pt. was tested in standing position.
Landmark Ant Post Lat
Head Eyes & ears symmetrical; ear lobes is Occiput is aligned c̄ Slightly forward head, ear
aligned c̄ acromion. No lat bending noted C7spinous process slightly ant to the humeral
head
Neck Trachea aligned c̄ sternum Occiput is aligned c̄ (+) capital flex
C7spinous process
Shoulder R acromion is aligned c̄ the L R shoulder blades is aligned Slightly protracted
c̄ the L
Trunk/spine Chest & rib flares evenly Aligned thoracic/lumbar Slight kyphotic thoracic;
vertebrae normal lumbar lordosis
Pelvis/hip R & L ASIS levelled R & L PSIS levelled (+) ant pelvic tilt
Knees (+) genu valgum (+) genu valgum B ant to lat malleoli.
 Ankle (+) pes valgus (+) pes valgus Neutral
Foot/Toes B malleoli are levels̄presence of in/out- B malleoli are level s̄ No deviations noted
toeing presence of in/out-toeing
Significance: Pt. exhibits a forward head & a slightly protracted shoulder which may lead to TOS.
A:
PT Dx:
Prioritized Problem List:
A:
PT Dx:
Prioritized Problem List:
1. 10/10 pain on R shoulder area
2. ↓ ROM on cervical flexion, extension, & B cervical rotation
3. (+) postural deviation
Evaluation: Pt.’s pain on R shoulder inhibits pt. to do ADL’s like carry heavy wt. objects s̄ difficulty; can benefit from
education on proper body mechanics, HMP + TENS, & US for pain; calliet ex. towards forward flex. & cervical ms.
Stabilization ex. to ↑ str.; Gentle passive stretching to ↑ mobility; may also benefit from postural correction ex. to ↓
incidence of re-injury.
Dx:
Practice Pattern: Neuromuscular Pattern G: impaired motor function & sensory integrity associated c̄ acute or chronic
polyneuropathies.
Prognosis: Pt has good prognosis because pt. is cooperative & motivated in all PT Mx given; wants to immediately
relieve pain to be able to lift heavy loads.
Focus of Rehab: To totally eliminate pain on R shoulder in order for pt. to resume in carrying heavy loads & to relieve
discomfort.
P:
LTG:
1. Pt. will be able to verbalize a total relief of pain on R shoulder p̂ 15 PTRx to be able to do ADL’s s̄ pain & difficulty.
2. Pt. will be able to achieve full ROM on cervical flexion, extension & B cervical rotation p̂ 15 PTRx to be able to do
ADL’s s̄difficulty.
3. Pt. will be able to perform proper body mechanics p̂ 10PTRx to ↓ chances of re-injury that may disable pt. to lift
objects.
STG:
1. Pt. will verbalize a ↓ in pain from 10/10 to 5/10 on R shoulder p̂ 8 PTRx to be able to do ADL’s s̄ pain & difficulty.
2. Pt. will be able to achieve an ↑ in ROM on cervical flexion, extension & B cervical rotation c̄ increments of 2°/
sessionp̂ 8 PTRx to be able to do ADL’s s̄ difficulty.
3. Pt. will be able to improve proper body mechanics p̂ 5 PTRx to ↓ chances of re-injury that may disable pt. to lift
objects.
PT Intervention Plan: Pt. will be seen as OP, TThF (1030H-1200H) & will receive the ff. PT mx.:
1. HMP + TENS on R upper back area x 20 mins. to relieve pain &↑ blood circulation
2. US @ 1.5 w/cm2 on R upper back area for ms relaxation.
3. Gentle passive stretching on R neck & back c̄ 5 sec hold x 10 reps for ms. relaxation.
a. R SCM
b. R rhomboids
4. Calliet ex towards forward flexionc̄6 sec hold x 10 reps to ↑ cervical strength.
5. Cervical stabilization ex while sitting on therapeutic ball towards flexion, extension, & diagonals
Suggested PT Mx:
Pt. Education:
1. Teach pt. proper posture.
2. Instruct pt. to rest if fatigue exhibits.
3. Always inform the PT if any discomfort is felt during the ex.
Precautions:
1. Re-injury
2. Fatigue

CALO-OY, GEIRARD LEY G.

CDU PT INTERN ‘19