INITIAL EVALUATION

I. General Information
- Patient’s Name : V.H - Rehab Dr :Dr. Andrew
- Age : 70 y/o Bautista
- Gender : Male - Date of Consultation : April 20, 2018
- Address : Marcos High way , - Date of IE : April 23, 2018
Baguio City - Diagnosis :Chronic L1-L2
- Civil Status : Married Radiculopathy
- Handedness : Right-handed - Precautions: Avoid lifting, prolonged
- Occupation : Business man positioning, activities involving carrying
- Religion : Roman Catholic heavy weights
c/c: Px c/o of intermittent, radiating pain c PS 4/10 on the L hip that extends to the lateral thigh aggravated by
prolonged standing, sitting and walking and was relieved by rest and taking medication; difficulty in bending
forward, difficulty in walking manifested by slow walking, and easily gets tired when standing c numbness on L
lateral thigh.

II. HPI:
Present condition started November 2017, when pt. noticed a difficulty in walking and bending forward
further manifested by pain on B hips c PS 4/10 aggravated by prolonged standing, sitting and walking ̴ 15’ and
was relieved by rest and taking medication prescribed by his son (unrecalled). Pt.’s son requested him to seek
medical consultation at SLU Sacred Heart Hospital under Dr. Bautista to request an X-ray (see ancillary
procedures). Pt. ignored his condition for ̴ 5 mos. April 2018 when pt. can no longer tolerated the pain c PS 8/10
and noticed that his condition was worsened during prolonged standing, sitting and walking. Pt. went to SLU
Sacred Heart Hospital PT rehab under Dr. Bautista for further evaluation and treatment and was then diagnosed
of having Lumbar radiculopathy L1-L2. Pt. recommended him to undergo PT Rehab to address his complain.
III. Ancillary Procedures:
Procedure/s Date/Hospital Results
X-ray November 2017 SLU Sacred Heart “thin spine”
Hospital

IV. Past Medical and Surgical History:

- (+) HTN controlled 2010
- (-) Hospitalization
- (-) Surgery
- (-) Stroke
- (-) Accidents
- (-) Fall
- (-) Trauma
- (-) Heart disease
- (-) Diabetes
- (-) RA
- (-) Asthma
- (-) Scoliosis

V. Medications:
Medication/s (Brand) Dosage/Route of Administration Indication
Unrecalled

VI. Personal, Social and Living Environment:

- Sedentary lifestyle
- Px works as a Business man.
 - Pt drives his grandchildren to school and goes to the market every morning which involves carrying ̴
15kg.

- Pt. spends his time by watching tv, reading newspaper at home.

- Pt has hx of

o (+) cigarette smoking

o (+) alcoholic beverage drinker (occasionally)

- Home situation:

o patient lives in a 2-storey house with his family

o Pt room is located at the 1st floor (2 flight of stairs, 10 steps)

o Pt’s sleeps in a sidelying on alternating position from R/L c 2 pillows

o Room to CR:~8m
o Room to kitchen: ~3m
o Room to main door: ~1m
o Room to living room: ~3m
VII. Family History:
Condition/s Mother Father
Asthma (+) (-)
HTN (-) (-)
Diabetes (-) (-)
RA (-) (-)
OA (-) (-)
Scoliosis (-) (-)
Heart Disease (-) (-)

Subjective:

c/c: “kumikirot na parang may kuryente at kasamang pamamanhid sa kanang pwetan ko hanggang side ng hita,
nahihrapan at mabagal yung paglakad ko, hirap din akong yumuko“
Prior level of function: Px was able to move in and out of bed and independent in ambulation.
Pt’s goal: “Gusto ko sanang mawala na yung sakit sa likod ko para hindi nako mahirapang tumayo at maglakad at
para comportable nako ulit mag trabaho”

O:
Vital Signs:
a p
BP 140/90mmHg 140/90 mmHg
HR 80 bpm 85 bpm
SPO2 95% 98%
Significance: for baseline data
Ocular Inspection:
- Ambulatory s AD
- A/C/C
- Endomorph
- (+) Postural deviation (see postural analysis)
- (+) dry skin on B UE/LE
- (-) Gait deviation
- (-)Deformity
- (-) atrophy
- (-) swelling
- (-) trophic skin changes
- (-) scars/bruises/wound

Palpations:
- Normothermic on all exposed areas
- Normotonic on all 4’s
- (+) minimal ms spasm on B low back
- (+) tightness on B hamstring
- (-) tenderness
- (-) taut bands
- (-) ms guarding
- (-) contractures

Sensory:

- Dermatomal/Peripheral
- Device used: pin for pain, brush for light touch and thumb for deep pressure

For brush For pin

Right Lef Right Lef
L1 100 % 50 % 100 % 50 %
L2 100% 50 % 100 % 50 %
L3 100% 50 % 100 % 50 %
- Findings:Px has decrease sensation (50%) on L LE
- Sig: 2o nerve impingement of femoral nerve

Deep Tendon Reflexes:

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

Findings: Normoreflexive on all 4’s

Significance: Intact reflex arc

ROM:
All major joints on B UE/LE were grossly assessed actively and passively and are WNL and Normal end-feel
except for:

Motion Right Left NROM Difference End-feel

AROM PROM AROM PROM R L
Hip flexion 0-60 0-65 0-65 0-70 0-120 60/55 55/50 firm

Findings: ↓ AROM on B hip flexion

Significance: LOM secondary to pain and mm tightness of Hamstring

MMT: All major ms are grossly graded 5/5 tested on supine position except for:
Muscle R L
L2 5/5 4/5

Findings: (+) decreased muscle strength on L2

Significance: 2o to Sig: decrease MMT gr d/t pain

SPECIAL TEST:
PROCEDURE POSITIVE SIGN RESULT Significance

ELY’s Test Pt is in prone Pt hip on the same (-) To r/o tightness

position, PT side also flexed of rectus
passively flexes the femoris
patients knee
SLR 5 Pt is in supine , PT Centralize pain on (-) T/C HNP
passively flex the hip the back
c the knee extended
the dorsiflexed the
foot
Pt is in prone Pain in the anterior (-) To r/o
Prone Knee Bend position ,the thigh tight/strained
Test examiner passively quadriceps
flexes the patient's muscle or
 knee to end range neural tension
and maintains it of the femoral
there for 45 nerve
seconds. The hip Pain on the To r/o lumbar
should not be unilateral lumbar radiculopathy
rotated. area, buttock, or of L2-L3 nerve
posterior thigh roots.

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:

Landmar Anterior/Posterior Lateral

k
Head Midline Slightly forward
Shoulder Leveled Leveled
Thoracic Leveled Increased Kyphotic Curve
Lumbar Leveled Decreased Lordotic curve
Pelvis Leveled Normal
Hip Leveled Normal
Knee Leveled Normal
Ankle Leveled Normal
Foot Leveled Normal

Findings: (+) postural deviation on A/P and Lateral view such slight forward head posture, increased kyphotic and
decrease lordotic curve.
Sig:: (+) postural deviation due to compensatory posture

ADL analysis

Pt is independent in all aspects of ADLs such as self care, bed mobility and transfer but has min difficulty in
performing ADLS such as:

 Dressing lower garment

 Difficulty in bending forward
 Prolonged walking, sitting and standing

A:
PT Impression:
A 29 y/o male who has diagnosed of having Lumbar radiculopathy L1-L2, manifested by min difficulty in
performing ADLS such as bending forward in dressing lower garment, activities which requires prolonged
walking and sitting c postural deviation, decreased (m) strength and LOM and c/o radiating pain c PS 4/10
starting from the L hip that extends to the lateral thigh.
Rehab potential: Pt. has excellent prognosis as to rehab since patient is cooperative and motivated and made
very good progress and responded well c Tx

Problem List:
1. Pt has min difficulty in performing ADLS such as bending forward in dressing lower garment, activities
which requires prolonged walking and sitting
2. Intermittent aching, radiating pain c PS 4/10 on the L hip that extends to the lateral thigh
3. Impaired sensation on L LE
4. Decreased muscle strength on L2
5. Pt has ↓ AROM on B hip flexion
6. (+) postural deviation
7. Ms spasm on low back
8. Tightness on of Hamstring

LTG(3x/wk for 12wks)

1. Pt will be able to to reach highest functional ROM and m strength s pain and difficulty in performing
ADLS such as bending forward in dressing lower garment, activities which requires prolonged walking
and sitting
2. Pt will report an eliminated radiating pain on the L hip that extends to the lateral thigh
3. Pt will achieve optimum level of muscle strength of target muscles c MMT gr of 5/5
4. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics

STG(3x/wk for 6wks)

1. Pt will report a decrease in pain by 2 increments in PS from 4/10 to 2/10 on the L hip.
2. Pt will demonstate an eliminated m tightness manifested by an increase in ROM by 10 0 increments
towards (B) hip flexion.
3. Pt will present an eliminated ms spasm on lower back

PT Management

Suggested PT Management:
1. Respectfully suggesting the pt to observe enough rest to be able to decreased the pain upon movt
2. Respectfully suggesting modification of pt’s work condition allowing less traumatic movements of the LE
3. Respectfully suggesting modifications of pt’s home situation such avoidance of tying of shoes and below
knee activities allowing less traumatic motions on shoulder
4. Pt. education on proper body mechanics and proper posture to avoid complications and/or further injury
5. Core strengthening exercises to strengthen probably weakened muscles
6. Home exercise program that include self-stretching of the 3 muscles
HEP:
1. Self-GPS
2. HMP x 15’ For Pain
3. Modification of home environment

Prepared By:

Gurtiza Joanna Eden

Lorma Colleges PT Intern ‘18