Saint Louis Hospital of the Sacred

Department of Physical Medicine and Rehabilitation

Baguio City
PT INITIAL EVALUATION

General Information: Referring MD: Dr. Posadas (Cardiologist)

Pt.’s Name: L.M Referring Unit: IPD
Address: Fair View, Baguio City Rehab MD: Dr. Jolyn Ruth Ambasing
Sex: F Date of consultation: April 25, 2018
Age: 36 Date of Referral: April 25, 2018
Civil Status: Single Date of IE: April 25, 2018
Occupation: Call center agent Diagnosis: CMS
Religion: Roman Catholic Precautions: Burn and dizziness
Nationality: Filipino During neck rotation toward right
Handedness: Right

C/C: Pt. c/o intermittent, dull aching pain on (B) paracervical area and upper traps
accompanied by headache on (B)suboccipital area to forehead c PS 6/10, felt during pt. was
stressed from work and was relieved by bed rest c ps 4/10.

HPI
Pt.’s present condition started 1
̴ 2hrs PTIE (1 am April 25, 2018), when was preparing to
go to her work when pt. noticed a severe dizziness, dull, aching sensation all over her head and
cramping pain her chest, pt. decided to go to SLU Hospital of the Sacred Heart Emergency
Room to seek medical advice. Pt. was attended by Dr. (unrecalled) and requested to undergo x-
ray (no result yet) and ECG. Pt. was then diagnosed of having Coronary artery Disease and
Stable angina, pt. was given medication (see medication). On the same day pt. was admitted
for further observation. Pt. has stable vital signs however pt. has dizziness during neck rotation
towards right. Upon Admission pt. notice heaviness and firmness as of her upper back
assessed by Dr. Posadas causing severe dizziness and headache from occiput to forehead c ps
6/10, pt.’s nurse gave her a hot compress and decrease the pain from 6/10 to 4/10. At 1 pm pt.
was attended by Dr. Posadas a cardiologist and was referred to SLU PT rehab under Dr.
Ambasing to address her complain and for further evaluation and tx.

Ancillary Procedure:
Date Result
X-Ray April 25, 2018 No result yet

Present Medication
Brand name Generic Dosage Indication
L-carnitine Carnicor 300 mg 2x a day To increase L-
carnitine levels
Clopidogrel clovix 70mg every 8 am For chest pain

FMHX:
CONDITION M F
HPN (+) (-)
Heart Dse (myocarditis) (+) (-)
Asthma (-) (+)
DM (-) (-)
CA (-) (-)

PMHX:
 (+) low back pain 10 yrs ago (12 PT tx session at Notre Dame de Chartes Hospital c a
dx lumbosacral strain , PT mx unrecalled )
 (+) Heart Condition (myocarditis 2006)
 (-) Asthma
 (-) CA
 (-) surgery
 (-) Previous Fall/Trauma
 (-) DM
 (-) Food and Drug Allergies

PSEHX:
 Pt. lives a sedentary lifestyle
 Pt. has a Type B personality
 Pt. has hx of
o (-) alcoholic beverage drinker
o (-) cigarette smoking
o (-) substance abuse.
 Work situation:
o Pt. works as a call center agent c 8hrs/day shift for 5 days.
o Pt. works involves prolonged sitting most of the time and taking calls.
o Desktop height ~3.5 ft.
o Pt. computer: 2-3” above seated eye level.
o Pt.’s chair: with backrest (foam)
 Home situation:
o Pt. does household chores such as cleaning and washing dishes.
o Pt. spends time in watching television preferring lying on bed during her day off.
o Pt. sleeps on a firm mattress and prefers side lying on either side c 1 pillow (~ 2”)
o Height of cabinet ~5ft
 Home dimension
o Room to CR:~6m
o Room to kitchen: ~5m
o Room to main door: ~5m
o Room to living room: ~5m

Subjective

C/c: “masakit yung batok ko at balikat, na may kasamang sakit ng ulo simula sa batok
hanggang forehead ko ”
 PT translation: Pt. c/o intermittent, dull aching pain on (B) paracervical area and upper traps
accompanied by headache on (B)suboccipital area to forehead c PS 6/10.

Pt.’s goal: to eliminate pain and to return from work

O:
VS:
Blood pressure Pulse rate Respiratory rate T° Spo2
Before 100/80 mmhg 72 bpm 17 cpm 36. 5 °C 97
After 100/80 mmhg 74 bpm 17 cpm 36.7°C 98
Findings: VS are WNL
Significance: For Baseline Purposes and precautionary measure to know if the pt is able to
proceed c the treatment and to monitor pt’s response to the treatment since pt has (+) heart
dse.
OI:
Ambulatory S Assistive Device
Endomorph
Alert/Coherent/Cooperative
(+) Postural Deviation (See Postural Assessment)
(-) Gait Deviation
(-) Attachments
(-) Deformity
(-) Swelling
(-) Atrophy
(-) Hematoma
(-) Scars/Bruises/Wound

PALPATION:
Normothermic on all exposed body parts
Normotonic on all fours
(+) minimal muscle spasm on B scalenes, upper traps, and levator scapulae R>L
(+) taut band on B upper traps and levator scapulae R>L
(+) gr 2 tenderness on B Upper traps and B suboccipitals
(+) Nodules on B rhomboids major
(-) muscle guarding

ROM:v
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 Passive Normal Difference End-
feel
L R L R Active Passive
Cervical L R L R
Lateral 0-32 0-32O 0-40 O 0-40 O 0-45 13 13 5 5 Tight
O
flexion degrees
Flexion 0-40 O WNL 0-45 5O WNL Tight
 degrees
O
Extension 0-40 WNL 0-45 5O 0-40 O
degrees
Rotation WNL 0-40O WNL WNL 0-60 WNL 20 O WNL WNL Tight
degrees

Findings: LOM on B Lateral flexion, cervical flexion extension and rotation

Sig: LOM 2o pain and dizziness towards R cervical rotation.

MMT: N/A d/t d/c PT tx and vertigo

Special Test: N/A d/t d/c PT tx and vertigo

Sensory: N/A d/t d/c PT tx and vertigo

Postural analysis
Postural landmarks are assessed in anterior/posterior and lateral views in a sitting position while
doing MRT and are found to be in normal alignment, except for

Landmark Anterior/Posterior Lateral

Head Midline Slightly Forward
Cervical midline Increase cervical lordosis
Shoulder Leveled Aligned
Scapula Leveled Aligned

Findings: (+) Postural Deviation, Pt. Manifest slightly forward head and an Increase cervical
lordosis
Significance: Pt may have postural compensation 2° to pain on paracervical area and upper

ADL analysis.
Pt. is independent in all aspects of adls such as self-care and ambulation.
A:
PT Impression:
Pt. is a 36 y/o call center agent who was diagnosed of having cervical musculoskeletal
strain, c/o intermittent, dull aching pain on (B) paracervical area and upper traps accompanied
by headache on (B)suboccipital area to forehead c PS 6/10. Pt. also presented c LOM of B
Lateral flexion, cervical flexion extension and rotation d/t tightness. Pt. has PD d/t habituation
and improper body mechanics while doing ADLS.

Rehabilitation Potential:
Pt. has good prognosis as to rehab since patient is cooperative and willing to learn and
responsive to Tx given.

Problem list:
1. Intermittent, dull aching pain on (B) paracervical area and upper traps accompanied
by headache on (B)suboccipital area to forehead c PS 6/10
2. LOM d/t Tightness on (B) upper traps, scalenes and levator scapulae, (R>L)
 3. muscle spasm on B scalenes, upper traps, and levator scapulae R>L
4. taut band on B upper traps and levator scapulae
5. gr 2 tenderness on B Upper traps and B suboccipitals
6. Nodules on B rhomboids
7. Postural deviation

LTG: TX 3x/wk x 4ks

1. Pt will be able to perform daily work s any pain and discomfort that would limit her
efficient job performance; Elimination of pain on (B) paracervical area and upper traps
accompanied by headache on (B)suboccipital area.
2. Pt. will be able to achieve normal ROM of cervical neck muscle

STG: Tx 3x/wk x 2 wks

1. Pt. will be able to state decrease pain sx from PS 6/10 to 3/10 on (B) paracervical area
and upper traps.
2. . will exhibit an eliminated m tightness on (B) upper traps, scalenes and levator
scapulae, (R>L) , muscle spasm on B scalenes, upper traps, and levator scapulae R>L,
taut band on B upper traps and levator scapulae and gr. 2 tenderness on B Upper
traps and B suboccipitals
P:

Suggested PT Mx:

1. HMP x 15 mins on trapz, rhomboids, levator scaps and paracervicals to decrease pt’s
pain
2. US 1.25 W/cm2 x 5mins on trapz, rhomboids, levator scaps and paracervical to
decrease pt’s pain
3. Effleurage to MRT to release mm tension
4. GPMS on paracervical, scalenes, levator scapulae, upper trapz, rhomboids x 30
seconds hold x 2reps to increase ROM
5. CNRSE x 7sh x 10 reps to relax and maintain the strength of the pt’s mm neck.
6. Pt. education on proper body mechanics and proper posture to improve posture and
avoid further strain
7. Kinesiotaping to provide support on B Upper traps and Cervical muscles extending from
acromion process to neck

HEP

a. Self-stretching techniques:
Precautions:
1. Burn
2. Dizziness

JELIAN MAE MAGATA, PTRP GURTIZA JOANNA EDEN A.

PT STAFF INCHARGE LORMACOLLEGES PTINTERN ‘18