MICHAEL B.

ASIA
BSPT2

SOAP
I.General Information
Pt. Name: J.B
Age: 16y/o
Sex: M
Address: Tabuk City, Kalinga
Civil Status: Single
Handedness: L
Occupation: Student
Religion: Catholic
Referring MD: Dr. M.A
Rehab Unit: KPH-Orthopedic Unit
Rehab MD: Dr. L.A
Date of Admission: March 16,2020
Date of Initial Referral: March 16,2020
Date of Initial Evaluation: March 16, 2020
Diagnosis: Juvenile Rheumatoid Arthritis (Polyarticular Arthritis)

II. HPI
A day PTIE, pt. states that he’s experiencing colored pink rashes on the
back of his neck and sometimes experience high spiking fever few months ago and then
one day, while he’s currently on field, and having school activities, Pt. suddenly felt a
dull aching pain (p/s 7/10) particularly on his fingers, wrist, elbow, knees and
shoulders. Pt immediately goes to his teacher and ask for permission to go at school
clinic and take ibuprofen (see meds taken). Pt later told to his mother his condition and
decides for immediate treatment and go to Kalinga Provincial Hospital for further
assessment and later undergo an (ancillary procedure). Pt was diagnosed JRA and later
referred to Orthopedic unit for further examination treatment.

Ancillary Procedures:
Procedure Date Result/Findings
X-Ray March 16, 2020 *soft tissue swelling
*Growth disturbance
*Loss of Joint Space
Laboratory Procedures:
CBC March 16, 2020 ↑ WBC
↓ Hgb
↑ Platelets
ESR March 16, 2020 Increase

Medication Taken
Drugs Dosage Indication
Ibuprofen 200 mg /qd (every 4-6 hrs) Reduce pain and fever
MICHAEL B. ASIA
BSPT2

Sulfasalazine 500 mg Reduce joint pain, stiffness

III.PAST MEDICAL HX
- (+)Chicken Pox
- (+)Mumps

IV.FAMILY MEDICAL HX
Condition Paternal Maternal
HTN (+) (-)
DM (-) (+)

V.PERSONAL SOCIAL ECONOMIC STATUS

-Pt is explorer
-Pt is athlete (Chess Player)

VI.HOME SITUATION
-Pt lives in a bungalow house with his 2 brothers and parents. Bedroom is 3m way from
the kitchen and the bathroom 2m away from the living room.

VII.CHIEF COMPLAINT

S:
C/C
“masakit ang magkabilang kamay ko, daliri ko, tuhod ko, at balikat.”

PT Translation:
“Pt c/o dull aching pain (p/s 7/10) on his hands,fingers,knees, and shoulders bilaterally”

PT Goal:
“Pt’s goal is to be able to minimize the pain”

O:

I.VS
a p
BP 110/70mmH 120/80mmHg
g
RR 16 cpm 18cpm
PR 90bpm 95bpm
Findings: All VS are WNL
Significance: For baseline purposes and assessment if pt is eligible for therapeutic
management

II.OI
MICHAEL B. ASIA
BSPT2

-Ambulation c +1 assist
-Alert, Coherent, Cooperative
-Mesomorph
-(-) Gait deviation
-(-) Deformity of UE and LE
-(+) Atrophy of UE and LE

III.PALPATION
- Normothermic on all exposure area
- Grade 1 tenderness
- (+)Muscle Spasm
- (+)Nodules
- (+)Subluxation

IV.ROM
All joints of (B) UE and LE were passively assessed and are WNL, painfree with normal
endfeels except for the following: Shoulder, Elbow, Wrist, and Knee.

Difference Normal
Motion Right Left Normal Right Left End-feel
Active Passiv Active Passive A P A P
e
Shoulder
Flexion 0-170 0-180 0-170 0-180 0°-180° 10 0 10 0 FIRM
Hyperextension 0-50 0-60 0-50 0-60 0°-60° 10 0 10 0 FIRM
Abduction 0-170 0-180 0-170 0-180 0°-180° 10 0 10 0 FIRM
IR 0-65 0-70 0-65 0-70 0°-70° 5 0 5 0 FIRM
ER 0-80 0-90 0-80 0-90 0°-90° 10 0 10 0 FIRM
Elbow & Forearm
Flexion 0-140 0-150 0-140 0-150 0°-150° 10 0 10 0 SOFT
Extension 140-0 150-0 140-0 150-0 150-0° 10 0 10 0 HARD
Pronation 0-70 0-80 0-70 0-80 0°-80° 10 0 10 0 H/F
Supination 0-70 0-80 0-70 0-80 0°-80° 10 0 10 0 FIRM
Wrist
Flexion 0-60 0-60 0-60 0-60 0°-80° 20 20 20 20 FIRM
Extension 0-60 0-60 0-60 0-60 00-700 10 10 10 10 FIRM
Hip
Flexion 0-120 0-120 0-120 0-120 0°-120° 0 0 0 0 SOFT
Hyperextension 0-20 0-20 0-20 0-20 0°-20° 0 0 0 0 FIRM
Abduction 0-45 0-45 0-45 0-45 0°-450 0 0 0 0 FIRM
Adduction 0-45 0-45 0-45 0-45 00-450 0 0 0 0 FIRM
IR 0-45 0-45 0-45 0-45 0°-45° 0 0 0 0 FIRM
ER 0-45 0-45 0-45 0-45 0°-45° 0 0 0 0 FIRM
MICHAEL B. ASIA
BSPT2

Knee
Flexion 0-120 0-125 0-120 0-125 0°-135° 15 10 15 10 SOFT
Extension 0-5 0-5 0-5 0-5 0°-10° 5 5 5 5 FIRM
Ankle
Dorsiflexion 0-20 0-20 0-20 0-20 0°-20° 0 0 0 0 FIRM
Plantar flexion 0-50 0-50 0-50 0-50 0°-50° 0 0 0 0 FIRM
Inversion 0-35 0-35 0-35 0-35 0°-35° 0 0 0 0 FIRM
Eversion 0-10 0-15 0-10 0-15 0°-15° 0 0 0 0 H/F

V.MMT
All major muscle groups were grossly assessed and are found to be 5/5 except for the
following: Shoulder, Elbow, Forearm, Wrist, and Knee with a grade of 3/5.

Muscle Group Right Left

Shoulder
Flexors 3/5 3/5
Extensors 3/5 3/5
Abductors 3/5 3/5
Adductors 3/5 3/5
Internal Rotators 3/5 3/5
External Rotators 3/5 3/5
Elbow
Flexors 3/5 3/5
Extensors 3/5 3/5
Forearm
Supinators 3/5 3/5
Pronators 3/5 3/5
Wrist
Flexors 3/5 3/5
Extensors 3/5 3/5
Radial Deviators 3/5 3/5
Ulnar Deviators 3/5 3/5
Hip
Flexors 5/5 5/5
Extensors 5/5 5/5
Abductors 5/5 5/5
Adductors 5/5 5/5
Internal Rotators 5/5 5/5
External Rotators 5/5 5/5
Knee
Flexors 3/5 3/5
Extensors 3/5 3/5
Ankle
MICHAEL B. ASIA
BSPT2

Dorsiflexors 5/5 5/5

Plantarflexors 5/5 5/5

VI. BADL
Activity Independent Independent Partially Dependent
with Aid Dependent
Self- care 
Bed mobility 
Transfer 
Ambulation 
Work 
Activities
Home 
Activities

A:
PT Impression: Good Rehab Prognosis
Problem List:
-Joint Pain or Stiffness
- Fever
-Pink Rashes
-Being less active
LTG: At the end of treatment, the pt will be able to bring back his functional level again
STG: Decrease pain scale from 7/10- 5/10

P:
-TENS (20 mins) cervical and shoulder area
-Hot packs (Lumbar and Cervical Area) 20 mins every tx session
-Theraband exercise 5 reps x 5 sec. hold
-Strengthening Exercise 10 reps x 10 sec. hold
-Weight Bearing Exercies 10 reps x 10 sec. hold
-Isometric Exercise- Prayer’s Pose
-Monday-Wednesday Treatment schedule

HOME INSTRUCTION:
-Home Exercise Program
-Joint Protection