I.

Initial Evaluation
Patients Name:

E.C

Age:

17 y/o

Sex:

Address:

Nagsabaran, Bangar, La Union

Civil Status:

Single

Handedness:

Right

Occupation:

Student

Religion:

Iglesia ni Cristo

Referring Unit:

OPD

Referring Dr:

Unrecalled

Rehab Dr:

Unrecalled

Date of Referral:

Unrecalled

Date of Consultation:

April 6, 2015

Date of Evaluation:

October 26, 2016

Diagnosis:

Mild Levoscoliosis, Cervical Spine

Mild Dextroscoliosis, Thoracic Spine

S:
c/c: sumasakit sa likod, PS 4/10
Pt Translate: pt. felt pain on its back c PS of 4/10
HPI: Pts present condition started 6 yrs ago PTIE when pt. felt pain on his neck c PS
of (1/10)
PMHx: (+) Heart Dse., Dislocation on elbow and thumb
FMHx:
DM
Htn
Heart dse.
Scoliosis

Mother
(-)
(-)
(-)
(-)

Father
(-)
(-)
(-)
(-)

PSEHx: Pt. lives in a bungalow house c his aunt and younger brother. Pt. has no hx of
substance abuse, non-smoker and non-alcoholic beverage drinker. Pt. sleeps in a side

lying or prone position on a banig. Pt. has an active lifestyle (occasionally plays
basketball, runs ~2km)
Goal: umayos nang konti
O:
VS:

BP

= 140/100 mmHg

PR

= 71 bpm

RR

= 15 cpm

Temp. = 36.9C
OI:

Manner of arrival: ambulatory s assist

Mental status: Alert/Coherent/Cooperative
Physique: Mesomorph
(+) postural deviation (see PA)
(-) trophic skin changes
(-) attachment

Palpation:
Thermal assessment: Normothermic
Tone assessment: Hypertonic on upper trapezius
(+) Gr.1 Tenderness on trapezius
(+) (m) spasm on (B) upper trapezius
(+) Tightness on upper trapezius
(-) Swelling
ROM:
Findings: All jts. of (B) UE/LE are actively and passively done WNL pain free c
N EF except:
Motion

Active

Passive

Norma
l

Cervical
Flexion
Extension
Lateral Flexion

0-34
0-50
0-30

0-40
0-60
0-34

0-50
0-60
0-45

Differences
Active
Passive
16
10
15

10
0
11

Endfeel

FIRM
FIRM
FIRM

(L) Lateral Flexion

0-20
Rotation
0-30
(L) Rotaion
0-50
Sig: 2 to faulty posture

0-34
0-42
0-56

0-45
0-60
0-60

25
30
20

11
18
4

FIRM
FIRM
FIRM

MMT:
Findings: All major (m) of B UE/LE are graded 5/5
Sig: 2 to immobility
ST:
(+) Adam Forward Test
(+) Rib hump
(+) Schobers Test
Landmark: C7-S2 (18.5 in/46 cm)
Initial Value
46 cm

Flexion

Extension

52 cm

37 cm

Differences
Flexion
6 cm

Extension
9 cm

Sig:
(+) Lat. Schobers Test
Landmark: Middle Finger - Floor
Initial Value
57 cm
(L) 56 cm
Sig:

Passive
39 cm
36 cm

Differences
18 cm
20 cm

PA:
Findings: postural landmarks are assessed in ant., post., and lat. views in
standing position and are found to be in N alignment except:
Anterior
Shoulder is higher

Posterior
Shoulder is higher than

Lateral
Forward Head

than (L)

(L)

(L) chest is prominent than

Clavicle is more

Asymmetrical spine

prominent than (L)

alignment

ear lobe is more anterior

Tip of the nose is not in

Neck is not in midline

than acromion process

midline

scapula is more

prominent than (L)

Neurologic Examination:
Sensory Testing:
Device used: pin for pain, brush for light touch, thumb for P
Findings: 100 %intact sensation
Sig: intact sensory pathway
DTR:
Legend:
0 Areflexia
+ Hyporeflexia
++ Normoreflexia
+++ Hyperreflexia

Findings: pt. is normoreflexive on (B) UE/LE

Sig: intact reflex arc
Functional Analysis:
ADLs

FIM LEVELS

Self-care

No Helper

Feeding: 7

7 - Complete Ind.

Grooming: 7

6 - Mod Ind.

Dressing: 7

5 - Min Ind. (subject 100%)

Bathing: 7

4 - Modified Dep, Min. Asst (75%)

Toileting: 7

3 - Modified Dep, Mod. Asst (50%)

Bed mobility
Roll to right: 7
Roll to left: 7
Supine to sit: 7
Sit to supine: 7
Transfer

2 - Complete Dep, Max Asst (25%)

1 - Complete Dep, Total Asst (<25%)

Bed to chair: 7
Sit to stand: 7
w/c to toilet: 7
Ambulation: 7
Sitting/ Standing Balance Tolerance

Sitting
Standin

Balanc
e

Tolerance
(mins.)

Legend:

N
N

Optimum
Optimum

0
P

Assume

Maintain

Weight-

Challenge

Shift
-

g
F
G
N

+
+
+

+
+
+

+
+

A:
PT Impression: Pt. is a 17 y/o student and has LOM in cervical flexion, extension, and
lateral flexions d/t tight post cervical (m), upper trapezius, tight (L) upper back (m)
Procedural Intervention: PT proposes, compensatory and preventative intervention c 3
Tx sessions/wk for 3mos.
Rehabilitation Prognosis: Pt. has good rehab prognosis
Problem List
1. Abnormal posture on ant.,

STG ( Tx Sessions)

LTG ( Tx Sessions)

post. and lat. view upon postural

assessment
2. LOM on cervical flex., ext., lat.

Pt. will ROM at least 3

Pt. will maintain

flex. and thoracolumbar flex.

increments p 6 Tx

optimum ROM achieve

3. Pt. has 3-/5 MMT on (L)

session for 2 wks

To (m) strength from

p the Tx session
To achieve optimum

cervical flex., ext., lat. flex., and

3-/5 to 4/5 p 8 Tx

(m) strength of the (L)

trunk flex.

sessions

cervical flex., ext., lat.

flex., and trunk flex.

4. (m) spasm on (B) upper

To eliminate (m) spasm

within 3mos.
To prevent further

back/trapezius

within 3wks. of Tx

complications

session

5. Pt. complains of dull aching

To pain on upper

To eliminate pain on

pain on upper back PS of 4/10

back p 4/10 to 2/10

upper back within 10 Tx

within 6 Tx sessions

sessions

P:
PT Mx:
Suggested Mx:
Precaution: