Initial Evaluation

PATIENT NAME: Ryan Gowing

DOB: 8/17/1994
EVALUATION DATE: 1/17/2019
DATE OF ONSET: September 2018

Referring Medical Diagnosis: Generalized Muscle weakness

Physical Therapy Diagnosis: Pectoral Major weakness and Abdominal muscle group weakness
Referring Physician: Dr. Smith

SUBJECTIVE: Patient reports “muscle weakness in abs and chest muscles.” Patient believes his
weakness is from sitting too often due to class, leading him to not work these muscle groups.
Patient stated that this affects him from participating in intramural softball and volleyball.

Patient Goals: Patient stated, “My goal is to get stronger in these areas so I can play softball and
volleyball for intramurals.”

General Demographics: 24 y.o., Caucasian male, English speaking.

History of Current Condition: Gradual onset since May/June of 2018.
Past History of Current Condition: Previous PT for injuries related to muscle weakness.
Past Medical/Surgical History: In August 2012, patient reports having R metatarsal fractures of
digits 3,4, and 5. In January 2015, patient had L thumb dislocation and hairline fracture as a
result of FOOSH. Patient had no surgeries.
Medications/Allergies: None.
Other Tests and Measures: X-rays performed on R foot (Sept 2012) and L hand (March 2015).
Social Habits (past and present): Non-smoker, social drinking, attends church regularly.
Social History: Engaged.
Family History: Parents divorced in 2005, patient has one younger sibling.
Growth and Development: None to be reported.
Living Environment: Lives in 3rd floor apartment with two roommates.
Occupational/Employment/School: Current graduate school student, undergraduate complete,
worked at Meijer for 1.5 years ending Jan. 7, 2019.
Functional Status/Activity Level: Minimally active, cardio and weight training 1-2x/week.
Health Status: Self-reported as good general health.

OBJECTIVE:

Systems Review:
HR: 72 bpm RR: 12 bpm BP: 128/88 taken on R arm in sitting position
Musculoskeletal: Grossly WNL UE’s for ROM, but weak strength.
Neuromuscular: Movement patterns WNL.
Cardiopulmonary: No edema present.
Integumentary: No discoloration present.
Communication Ability, Affect, Cognition, Language and Learner Style: Patient is a visual
and verbal learner. He prefers written HEP with pictures and descriptions.
Other significant findings:

Formula: Hetherington 1RM = Weight lifted / (1.0278-0.0278(# of Reps))

• Chest Press machine: 1RM: 115 lbs. = 115 / (1.0278-0.0278(1))
• Pectoral Fly machine: 1RM: 175 lbs. = 175 / (1.0278-0.0278(1))
• Bench Press: 1RM: 125 lbs. = 125 / (1.0278-0.0278(1))
• Abdominal Crunch machine: 1RM: 200 lbs. = 150 / (1.0278-0.0278(10))
• Torso Rotation: 1RM: 186.7 lbs. = 140 / (1.0278-0.0278(10))
• Russian Twists: 1RM: 10.67 lbs. = 8 / (1.0278-0.0278(10))

Arousal, Attention, and Cognition: A&O X 3.

Environmental, Home, and Work Barriers: Sits for majority of the day for class.
Integumentary Integration: Normal skin coloration; no cuts, tattoos, or abnormalities.
Motor Function – Control and Learning: WNL.
Muscle Performance – Strength, Power, Endurance:
MMT:
• Pectoral MMT: 3+
• Abdominal MMT: 3+
Pain: 0/10 using Visual Analog Scale, no position makes it better or worse since pt has no pain.
Posture: Forward head posture, rounded shoulders, hyperkyphotic thorax curvature, flat-back.
Range of Motion:
Pectoralis Major:
AROM: 0°-120° PROM: 0°-130°
Forward Bending of entire Spine:
AROM: 0°-100° PROM: 0°-110°
Reflex Integrity: Normal DTR’s intact.
Sensory Integrity: Light touch, sharp-dull, temperature, and two-point discrimination intact.

ASSESSMENT:

Problems List:
• Muscle weakness in Pectoralis Major
• Muscle weakness in Abdominals
• Limited time to get physical activity
• Patient can’t participate in intramural sports

Summary-Clinical Impressions: Due to patient’s muscle weakness in Pectoralis Major and

Abdominals, he is unable to participate in intramural sports. Patient needs physical therapy to
strengthen muscles to return to sports. Patient tolerated first session well and appears motivated
to initiate intervention.

Rehabilitation Potential: Good

Goals:
Short Term Goals: Within 2 weeks the patient will increase strength in abdominals and
pectoralis muscles 25% in order to get stronger to participate in sports upon discharge.
 Long Term Goals: Within 6-8 weeks, the patient will increase strength in abdominals
and pectoralis muscles 75-100%, reach MMT grade 5/5, and return to sports.

PLAN OF CARE:

Frequency of visits will be: TIW

Duration of visits will be: 6 weeks

Re-Examination: Re-Examine in 2 weeks with similar tests and measures, modify plan to
progress patient’s therapeutic exercise.

Criteria for Discharge: Patient reaches established functional goals or is unable to progress.

Treatment will consist of therapeutic exercises described and pictured below and postural
education. Patient will start each exercise at 25% of 1RM weight and progress to 85% of 1RM
weight until strength has improved over the next 6 weeks. Each amount of weight, sets, reps, and
frequency of treatment is outlined below, under each individual exercise. Patient will be
educated on how to perform and use equipment correctly for each exercise described below.
Patient will be educated on postural adjustments to make while sitting in the classroom.

INTERVENTION: Patient signed informed consent and gave verbal consent for treatment.
Patient is willing to participate in the POC.

Patient Related Instruction: Initiate HEP, written and verbal instructions, patient education on
posture.

Direct Interventions:
1. Therapeutic Exercise: Strengthening program.
2. Functional Training in Community and Work Integration: Postural training for
classroom sitting.

CHEST PRESS MACHINE

Before sitting in the seat, adjust the arm placement to 2 on both sides.
Adjust seat height to 6. Adjust the weight to instructed amount. Sit on
seat with good posture, place hands on bars, and push directly away
from your body.
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
25% 37.5% 50% 65% 75% 85%
1RM 1RM 1RM 1RM 1RM 1RM
Hold: No Hold 29 lbs. 43 lbs. 58 lbs. 75 lbs. 86 lbs. 98 lbs.
Perform: 3x per Week 3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
8 reps 8 reps 8 reps 8 reps 8 reps 8 reps
 PECTORAL FLY MACHINE

Before sitting in the seat, adjust the arm placement to 3 on both sides.
Adjust seat height to allow feet to be flat on ground and the weight to
instructed amount. With arms straight, bring both hands together.

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

25% 37.5% 50% 65% 75% 85%
1RM 1RM 1RM 1RM 1RM 1RM
44 lbs. 65 lbs. 88 lbs. 114 lbs. 132 lbs. 148 lbs.
Hold: No Hold 3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
Perform: 3x per Week 8 reps 8 reps 8 reps 8 reps 8 reps 8 reps

BENCH PRESS

Before laying on the bench, make sure to have someone spot you
while benching. Place weights on each side of bar as instructed below,
securing them with clamps to prevent them from coming off. Lay
down on bench, feet flat on ground with a slight arch in the lower
back, bring the bar to chest and push straight up.
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
25% 37.5% 50% 65% 75% 85%
1RM 1RM 1RM 1RM 1RM 1RM
Hold: No Hold 31 lbs. 47 lbs. 62 lbs. 81 lbs. 94 lbs. 106 lbs.
Perform: 3x per Week 3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
8 reps 8 reps 8 reps 8 reps 8 reps 8 reps

ABDOMINAL CRUNCH

Before sitting in the seat, adjust the seat height for feet to be
completely on the ground and adjust the weight to instructed amount.
With correct posture, place hands on the bars with forearm resting on
the pads. Use your stomach muscles to bring arms closer to the
ground. Do not use arm strength to move.

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

25% 37.5% 50% 65% 75% 85%
Hold: No Hold 1RM 1RM 1RM 1RM 1RM 1RM
Perform: 3x per Week 50 lbs. 75 lbs. 100 lbs. 130 lbs. 150 lbs. 170 lbs.
3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
8 reps 8 reps 8 reps 8 reps 8 reps 8 reps
 TORSO ROTATION

Before kneeling on the machine, adjust the angle of the bottom chair
to 45°. Adjust shoulder pads to comfort shoulder height level and the
weight to instructed amount. While kneeling tall, place hands on the
bars, have shoulders touch pads, and rotate knees to opposite side.
Only the lower body should be moving.
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
25% 37.5% 50% 65% 75% 85%
1RM 1RM 1RM 1RM 1RM 1RM
Hold: No Hold 46 lbs. 69 lbs. 93 lbs. 120 lbs. 138 lbs. 157 lbs.
Perform: 3x per Week 3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
8 reps 8 reps 8 reps 8 reps 8 reps 8 reps

RUSSIAN TWISTS

Place yoga mat on floor. Sit on ground, lean back slightly, and lift
legs off ground to create a “V” position. With the weighted ball in
hands, rotate from side to side and try to make the ball touch the
ground on each side.
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
25% 37.5% 50% 65% 75% 85%
1RM 1RM 1RM 1RM 1RM 1RM
2.5 lbs. 3.75 lbs. 5 lbs. 6.5 lbs. 7.5 lbs. 8.5 lbs.
Hold: No Hold
3 sets 4 sets 5 sets 3 sets 4 sets 3 sets
Perform: 3x per Week
8 reps 8 reps 8 reps 8 reps 8 reps 8 reps

Elizabeth M. Osantowski, Student Physical Therapist

1/17/2019
Date
 PTH 646 Therapeutic Interventions I
PRE Report Scoring Criteria

Date: ______________Student Evaluator LO

Subject: RG Faculty Reviewer Initials: PS

EVALUATION Value Points Comments

Subjective 1 1 Pertinent information sufficient to recognize patient,
Information – Patient lack of problems noted.
name/age/birth date,
brief description of
pertinent injuries or
identified problems
Objective Findings - 1 0.80 May include other objective info, such as postural
Appropriate reporting alignment, balance or stability may help to
of understand.
MMT/RM information You have medical and PT diagnosis but it would be
better to specify as follows: PT Diagnosis (ICD-10):
M62.81 – muscle weakness (generalized)
Assessment 1 1 Good reporting about initial response to training and
Tolerance for initial education. Motivation and barriers discussed.
session
Deficits identified
Barriers to adherence
Motivation to adhere
Plan 1 1 Due to the nature of the muscle imbalance, those
Outline program exercises need to be incorporate with stability of
Progression of trunk, shoulder and pelvic floor muscles. Postural
resistance, reps, and correction or precaution, training response, any
sets over time frames problems for specific instruction might be noted.
Summary program was good to understand the plan.
INTERVENTION
STRATEGY
Hand-drawn exercises 1 1 Pretty artwork with positive results pictured!
Appropriate exercises 1 1 Exercises easy to reproduce.
targeted to identified
deficits
Use of calculations or 1 1 Easy to follow and clear about details.
methods of
determining resistance
loads for all 6
exercises (may have
already been
identified)
Exercises easily 1 1 Good variety of exercises, appropriate for identified
performed by average muscles.
patient in clinic or
gymnasium;
Ease of interpretation
Appropriate length of 1 1 Excellent!
overall report (3-5
pages), deductions for
>5 pages

Clarity of overall 1 1 Excellent!

report, coherent and
consistent material,
grammar
Totals (10) 9.8
Percentage 98% Nice work! This is one of the best!
You are on your way to being an excellent therapist!