Initial Evaluation

NAME: Boglosa, Alfie DATE OF I.E: Febuary 20,2019

SEX: ♂ DATE OF Adm: N/A
ADDRESS: Dumangas, Iloilo City DATE OF REFERRAL: Unrecalled
DOB: January 28, 1987 REFERRING MD: Dr. Canonero
NATIONALITY: Filipino PHYSIATRIST: Dr.Gicos, Adrilee Herrera
RELIGION: Roman Catholic Dx: HNP on L5-S1
OCCUPATION: Vending machine technician Meds: Mecobalmin 500mg OD
HANDEDNESS: ®
CIVIL STATUS: Single

/S/:
C/C:Pt. complains of intermittent localize cramping pain on the (B) paralumbar graded 7/10 (0=
no pain, 10= worst pain) & on e R hamstrings area graded 5/10 and usually happens during
p.m p work. .
HPI: Pt’s current condition started last Dec 2018, upon doing his monthly maintenance of the
vending machines located @ Manduriao. Stated they brought several machines down from the
3rd floor of the building towards their truck. They used a lifter to lift the machines to be placed
inside their truck when suddenly the lifter malfunctioned and requires assistance upon lifting the
last machine; states about 8 of them assisted the lifter. During the lift pt suddenly felt a pop on
his back and felt a tolerable cramping pain of 3/10 but didn’t mind about it & continued assisting
the lifter .p his work he felt minimal pain but was lost after he went back to their warehouse
where he is staying during e weekdays. After a week, he went to his father’s fishery to help feed
the fishes when suddenly felt an intense cramping pain on his back graded 9/10 which resulted
for him to stop feeding & rested throughout the day; applied linamental oil & massage several
times which ↓ e pain but is still constant. On e first week of Jan 2019, pt. decided to go to Iloilo
Doctors Hospital (IDH) ;was assessed & evaluated. Pt had (-) findings on e ultrasound & (+)
mild compression L5-S1 on e X-ray findings ;was referred by Dr. Canonero to Dr. Gicos for PTR
@ (IDH) but pt requested to start his PTR session @ PORI because of e location ; states e pain
decreases & was able to get back to work which gives e ideo to not con’t his PTR session. On
Feb 14, 2019 , upon fixing a broken vending machine, he suddenly felt a cramping pain on his R
hamstrings area which hinder his job for almost a whole week. Pt then returned to Dr. Canonero
& was advise to undergo a MRI scan which shows a bulging & compression on L5-S1; was
advise to con’t PTR under Dr. Gicos.
Pt goals: Pt wants to be pain free & return to his previous level of function.
Prior level of function: Pt. was amb. S assist device; used to do ADLs & IADLs s difficulty.
Social Hx: Pt. lives c with his workmates @ their warehouse thought e week; returns to their
house every weekend where he lives c 5 siblings that is able to help him do his IADLs & has no
religious belief that may hinder quality of care.
Employment status: Pt.is a vending machine technician ; works on his feet and & seldom
carries heavy materials for e repair ≈ 5 hrs. from mon. to fri..
Living Environment: Pt. lives in a bungalow house c cemented floor; has a stairs c 5 steps & s
railing upon entering main door; pt sleeps & stays in e living room ≈ 3 steps from main door;
living room↔C.R ≈ 4 steps; living room ↔ dining room ≈ 5 steps.
General Health Status: Pt. rates health status as fair, s any major life changes that occur from
last year prior to e incident.
Social Health Habits: Pt. denies smoking but occationally drinks alcoholic beverages & is
active playing basketball almost every weekends.
Family Health Hx.
Condition Mother Father Patient
CA (-) (-) (-)
HTN (-) (-) (-)
Cardiac conditions (-) (-) (-)
DM (-) (-) (-)
Allergies (+) (-) (+)

Patient’s Medical/Surgical Hx: Had not undergone any med/surg Hx & denies admitted to e
hospital prior to e incident.
Medications: Pt states he’s taking Mecobalmin 500mg , a multivitamin OD.
Functional Status: Pt. is indep. towards all aspects of ADLs & IADLs.
/O/:
OI: Pt. is mesomorphic; amb s AD, (+) postural deviation & (-) gait deviation.
Cardiovascular System: Unimpaired

A P Location
BP(mmhg) 110/70 110/80 (R) brachial artery,
auscultatory,supine
HR (BPM) 70 70 (R) Radial artery,
palpatory, supine)
RR(CPM) 20 20 (Diaphragmatic breathing,
supine)
Integumentary System: unimpaired
Integumentary disruption :unimpaired
Skin color: unimpaired
Skin pliability& turgor: unimpaired
Musculoskeletal System: Impaired
Gross symmetry: impaired
Gross ROM: impaired
Gross mm. Strength: impaired
Neuromuscular system: unimpaired
Gait: unimpaired
Transfers: unimpaired
Balance: unimpaired
Motor function: unimpaired
Communication: unimpaired, pt converses fluently & spontaneously; able to answer
questions in a timely manner.
Affect: emotional and behavioral responses are unimpaired
Cognition: Pt is oriented x 3 ( person, place & time)
Learning barriers: unimpaired, able to understand & comprehend instructions given.
Learning style: pt. Learns best when demonstrated & visual presentation of e given
exercises is conducted.
Educational needs: Pt needs proper body mechanics in sitting, standing & proper
carrying
techniques to prevent further aggrevation of current symptoms.
TESTS AND MEASURES
Sensory Integrity:All exposed dermatome patterns were grossly assessed & graded
normal
(STD used: small nylon brush, for light brush; sharp for pain; & dull end of a reflex
hammer for dull)
DTR:
R L
Legend:
++ ++
N/A- not assessed
++ ++
++ ++ 0-Absent

+-Hyporeflexive
++ ++
++-Normoreflexive

+++-Hyperreflexive
++ ++
++++- Clonus
Sig: Pt has an intact DTR reflex indicating an (-) UMNL & LMNL.
ROM: All major joints of the L side of the body were passively assessed & were found
to be WNL c normal end feel except:
Motion N AROM DIFF PROM Diff End-Feel

R hip flexion 0-120° 0-70° 50° 0-80° 40° Firm

L Hip Flexion 0-120° 0-90° 30° 0-100° 20° Firm

Modifed schober test N° Starting Value Difference
position

Lumbar flexion >4cm = mild 15cm 12cm 3cm

2-4cm = mod
<2cm =

sever

Sig:Pt shows LOM towards lumbar flexion & (B) hip flexion due to pain on (B) para lumbar 2 ° HNP on
L5-S1.

MMT:All major muscle groups of the body were grossly assessed and graded
5/5except for the ff.
N 5 Full available ROM, against gravity, strong
Muscle groups Grade
manual resistance
Thoracolumbar 4/5 Good 4 Full available ROM, against gravity, moderate

flexors manual resistance

Fair Plus 3+ Full available ROM, against gravity, slight manual

R Hip flexors 4/5
resistance
L Hip flexors 4/5 Fair 3 Full available ROM, against gravity, no resistance

Fair minus 3- At least 50% ,but not full ROM,against gravity

,no resistance

Poor 2 Full available ROM, gravity minimized, no

resistance

Poor minus 2– At least 50% but not full ROM, gravity

minimized, no resistance

Trace 1 No observable motion, palpable muscle

contraction, no resistance

Zero 0 No observable or palpable muscle contraction

Sig:Pt presents weakness of Thoracolumbar musculature & (B) Hip flexors due to muscle imbalance
resulting to pain 2° HNP on L5-S1.
Balance and tolerance assessment:
BALANCE TOLERANCE

SIT 4 Good

STANDING 4 Fair+

WALKING 4 Fair+

Balance Grading:
4 Normal Pt. able to maintain steady balance s
support(static); Accepts maximal challenges, shift
weight easily c full range in all
directions(dynamic).
3 Good Pt. able to maintain balance s support, limited
postural sway(static); Accepts moderate
challenges, maintain balance while picking
objects off the floor(dynamic)
2 Fair Pt. able to maintain balance c handheld
support(static); May receive occasional minimal
assist (dynamic); Accept minimal challenge, able
to maintain balance while turning head/trunk
1 Poor Pt. requires handhold et moderate to maximal
assist to maintain posture. Unable to accept
challenge

Tolerance Grading:
Poor: <15 min
Poor +: 15-30 min
Fair: 30-45 min
Fair +: 45-60 min
Good: >60 min

Sig: Pt’s has ↓Tolerance in standing & walking due to cramping pain from (B) para lumbar & R
hamstrings area 2 ° HNP on L5-S1.

Special Test
Special test (+) response Procedure Pt. response Significance
Adam’s forward rib hump on Pt. bends forwards (-) Postural
bending test convex side of maintaining the Scoliosis
spine knee straight and
30 cm feet apart,
Lasegue Test / 30-70°Radiating Pt. is place in (-) Lumbar
SLR pain on e leg / supine ; flex leg radiculopathy
Numbness of e leg
 while maintaining
knee extended

Functional Assessment- ATDEP

Ambulation: Pt. is indep s assist device but have ↓ tolerance in standing & walking.
Transfer: Pt. is indep towards all type of transfers.
Dressing: Pt. is indep in dress UE & LE garments but seldom feels e pain on (B) para
lumbar during dressing LE.
Eating: Pt can eat indep.
Personal hygiene; Pt. is indep. as well as during bowel managements.
Postural Assessment: ( note: Pt. was assess in standing position)
Ant. View/ Post view Lateral View
Head Eyes & ears are symmetrical no Ear lobes is slightly forward
lat.bending noted. with acromion.
Neck No tracheal deviation noted; Neck is ↑ Lordosis / slightforward

aligned c sternum. head; chin slightly

out

Shoulders Shoulders are level / Symmetrical Protracted scapulae; Ant,

displacement of
shoulders
Spine Spine is neutral Spine is neutral
Hips ASIS & PSIS aligned ASIS & PSIS aligned
Knees B patella aligned Neutral
Ankle & foot B lateral & medial malleolus are B lat. Malleolus in line c lat.
equal/level. Condyle.
Sig. Pt has ( + ) slight forward head posture due to muscle imbalance 2° to bad postural habit.

/A/:
Problem list:
1. Intermittent cramping pain on (B) para lumbar graded 7/10 & R hamstrings graded 5/10.
2. LOM on lumbar flexion & (B) hip flexion.
3. Muscle weakness on thoracolumbar flexors & (B) hip flexors.
4. (+) Postural deviation.; forward head posture
5. ↓ Tolerance in standing & walking.

PT impression: Pt.has LOM on lumbar flexion & (B) hip flexion & weakness on
thoracolumbar flexors & (B) hip flexors due to pain which limits pt’s performance during
work & IADLs such as washing clothes , cleaning his motorcycle & has a forward head
posture which can further complicate pt’s current symptoms. Pt. may benefit from
strengthening exercises & GPS to ↑ ROM to correct posture & muscle
imbalances , TENS to ↓ pain & Intermittent lumbar traction to decompress spine.
Practice Pattern: musculoskeletal pattern F: Impaired Mobility, Motor Function,
Muscle Performance, Range of Motion and Reflex Integrity Associated With Spinal
Disorders.

/P/
LTG
1. Pt will experience a ↓ rate of pain from 7/10 → 3/10 on (B) para lumbar & pain free on R
hamstrings p 1 mos of PTR to promote return level of performance in doing IADLs & in
work c less limitation.
2. Pt will be able to demonstrate a full ROM p 6 wks of PTR session to be able to promote
prior level of function & to prevent re occurrence of patient symptoms.
3. Pt. will be able to demonstrate a normal muscle strength on thoracolumbar flexors & (B)
hip flexors 2 mos of PTR session to be able to return to prior level of performance in
work, ADLs & IADLs
4. Pt will show improvements of posture p 1 mos of PTR session to prevent complication
such as ↓ chest expansion that may affect cardiopulmonary system & LOM due to
muscle imbalances which can further complicate pt’s current symptom.

STG
1. Pt will demonstrate a ↓ rate of pain from 7/10 → 5/10 on (B) para lumbar & 5/10 → 3/10
on R hamstrings p 2wks of PTR session to gradually promote return of function & work
c less limitation.
2. Pt will be able to demonstrate an ↑ ROM c an increments of 5 p 3wks of PTR session to
gradually ↓ limitation upon doing IADLs & work performance.
3. Pt. will be able to demonstrate a good muscle strength on thoracolumbar flexors & (B)
hip flexors 6wks of PTR session to gradually be able to return to prior level of
performance in work, ADLs & IADLs
PT Mx: Pt. will be seen as an OP 3 times/wk ( MWF) (4:00p.m. – 5:00p.m.) c the ff Mx:

1. HMP on (B) para L5 area & R hamstrings x 20 mins ↑ tissue extensibility.

2. TENS on (B) para L5 area x 20 mins to ↓ pain.
3. Phonopohresis @ US 1.5 w/cm2 x 5 mins c prescribed gel t B para L5 area.
4. Deep kneading massage to (B) para L5 area for pain relief.
5. McKenzie extension exercises to ↑ lumbar strength & correction of muscle imbalances.
6. GPS on (B) hamstrings x 30SH x 3 sets to ↑ ROM.
7. ILT @ 23kg max pull, gradually ↑ by 1 kg/session until 33kg for spinal decompression.
Recommendations/Suggestions/:
1. Chin tuck exercise x 6 sh x 20 resps x 2 sets to correct forward head posture.
2. GPS on pectoralis musculature using PNF pattern (B) symmetrical D2 flexion c 30SH x 3
sets to correct posture.
HEP:
1. (B) hamstring stretch using towel c 30 sh x 2 sets to ↑ ROM.
2. Chin tucks exercises x 6SH x 20 reps x 2 sets to correct forward head posture.
3. McKenzie 1-3 to ↑ lumbar strength & correction of muscle imbalances.
Precautions:
1. Proper body mechanics upon during carrying objects.
2. Fatigue
3. Pain

Rene Sandlee Orate

CDU PT intern’19