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INITIAL EVALUATION

General Information
- Patient’s Name : E.A - Religion : Roman Catholic
- Age : 40 y/o - Rehab Dr :Jolyn Ruth
- Gender : Female Ambasing, FPARM
- Address : Asin Rd. Baguio - Date of Referral : April 10,2018
City - Date of IE : April 11,2018
- Civil Status : Married - Diagnosis : T/C piri L>R MSC
- Handedness : Right-handed strain
- Occupation : Housekeeper
c/c: Px c/o of intermittent radiating pain c PS 7/10, numbness on the R buttock that extends to the posterior
thigh. Aggravated by prolonged sitting ~15 mins and, upon waking up in the morning c PS 8/10 and was relieved
by taking self-prescribed medication(arcoxia) and doing stretching c PS 5/10.

HPI:
Present condition started 2015 when px had her last birth of her last child and starts an
intermittent dull aching pain on (B) lower back c PS 5/10. Px also noticed a persistent of pain p 4 hrs of travel c
PS 6/10. Px managed the pain by having a masage 2x a week which ↓ the pain to 4/10.
March 2018, when px felt of intermittent radiating pain c PS 7/10 on the R buttock that extends to the
posterior thigh. Aggravated by prolonged sitting ~15 mins , upon waking up in the morning c PS 8/10 and was
relieved by taking self-prescribed medication(arcoxia) and doing stretching c PS 5/10.
April 11, 2018 d/t persistent of pain and bothers her during sleep pt went to SLU Sacred Heart hospital
PT rehab and was attended and by Dr. Jolyn Ruth Ambasing, FPARM a rehab doctor. Px was requested to
underwent x-ray (unrecalled). Px was then diagnosed with piriformis strain. Px recommended her to undergo PT
Rehab to address her complain.

Past Medical and Surgical History:


- (+) Hospitalization @ SLU Sacred Heart hospital d/t slip disk
o Pt. underwent 12 PT tx session for yr 2007-2009 @ SLU Sacred Heart hospital PT rehab
o
- (-) Surgery
- (-) HTN
- (-) Accidents
- (-) Fall
- (-) Trauma
- (-) Heart disease
- (-) Diabetes
- (-) RA
- (-) Asthma
- (-) Scoliosis

Medications:
Medication/s (Brand) Dosage/Route of Administration Indication
Vitamin B complex (neurogine E) 1x a day Numbness

Personal, Social and Living Environment:


- Sedentary lifestyle
- Pt has no hx of
o (-) cigarette smoking
o (-) alcoholic beverage drinker
- Home situation:
o patient lives in a 3-storey house with his mother
o Pt room is located at the 2th floor (2 flight of stairs, 10 steps)
o Room to CR:~6m
o Room to kitchen: ~4m
o Room to main door: ~4m
o Room to living room: ~3m
- Work situation:
o Px works as a housekeeper and take care of her children
o Pt. spends her time by watching television

Family History:
Condition/s Mother Father
HTN (-) (+)
Diabetes (-) (+)
RA (-) (-)
OA (-) (-)
Scoliosis (-) (-)
Heart Disease (-) (-)

Subjective:

c/c: “kumikirot na parang may kuryente at kasamang pamamanhid sa kaliwang pwetan ko hanggang likod ng
hita“
Prior level of function: Px was able to do household chores washing dishes and clothes.
Pt’s goal: To be able to work pain free and can tolerate prolonged sitting

O:
Vital Signs:
Initial vs
BP 130/80mmHg
HR 88 bpm
SPO2 98%
Significance: for baseline data
Ocular Inspection:
- Ambulatory s AD
- A/C/C
- Endomorph
- (+) Postural deviation (see postural analysis)
- (+) Gait deviation (see gait analysis)
- (-)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 piriformis
- (+) gr 1 tenderness on (B) piriformis
- (+) taut band on ® Lower back
- (-) ms guarding
- (-) nodules
- (-) contractures

Sensory:

- Dermatomal/Peripheral
- Device used: pin for pain, brush for light touch and thumb for deep pressure
- Findings:Px has intact sensation (100%) on R & L UE/LE
- Sig: for baseline purposes

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 AROM PROM R L R L
Hip flexion 0o-75o 0o-90o 0o-62o 0o-85o 0o-120o 45o 580 30 380 empty
Thoracolumbar 0o-30o 0o-35o 0o-28o 0o-30o 0o-45o 150 170 100 150 empty
lateral flexion

Findings: ↓ ROM on R/L Hip flexion and thoracolumbar lateral flexion


Significance: LOM on R/L Hip flexion and thoracolumbar lateral flexion d/t tightness of piriformis

MMT:

All mm group of B UE/LE are grossly graded 5/5


Findings: N ms strength on B UE/LE
Significance: For baseline purposes

SPECIAL TEST:
PROCEDURE POSITIVE SIGN RESULT Significance
Piriformis Test The patient is reproduction of (+) piriformis
positioned sidelying. gluteal pain or tightness
The test limb is radicular
taken into flexion, symptoms in the
adduction and distribution of the
internal rotation. sciatic nerve.
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
Prone Knee Bend Pt is in prone Pain in the anterior (-) To r/o
Test position ,the thigh tight/strained
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:

Landmark Anterior/Posterior Lateral


Head Midline Slightly forward
Shoulder Right > Left Sh is aligned
Thoracic Levelled N Kyphotic Curve
Lumbar Levelled Decrease lordotic
curve
Pelvis Levelled Normal
Hip Levelled Normal
Knee Levelled Normal
Ankle Levelled Normal
Foot Levelled Normal

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

Gait Analysis:
Stance Phase R L
HS (-) (-)
FF (+) (+)
MS (+) (+)
HO (+) (+)
TO (+) (+)
Swing Phase
IS ↓ ↓
MS ↓ ↓
TS ↓ ↓

Findings: Decrease swing phase on both Right & Left, (-) HS on both right & left feet
Sig: 20 antalgic gait

ADL analysis

Pt is independent in all aspects of ADLs such as self care, bed mobility and transfer
Balance & Tolerance
Legends:
TOLERANCE BALANCE
Poor- 0-15 min 1- Can assume
Fair 16-30 min 2- Can assume & maintain
Normal 46-60 min 3- 2+ Can assume, maintain, & weight shift
4- 3+Can assume, maintain, weight shift, & challenged

Balance Tolerance
Sitting N F
Standing N F

Findings: Px has normal sitting & standing balance but has fair tolerance in sitting for 20 min
Significance: 2 to radiating pain
A:
PT Impression:
- A 40 y/o female that has been diagnosed of having T/C piri L>R MSC strain, c/o of constant dull aching,
numbness and radiating pain c PS 7/10 on the R buttock that extends to the posterior thigh further
manifested by LOM on hip flexion and thoracolumbar lat. Flexion, minimal ms spasm on B piriformis, gr
1 tenderness on (B) piriformis L>R) , taut band on ® Lower back and postural and gait deviation.

Rehab potential: Pt. has excellent prognosis as to rehab since patient is cooperative and motivated and made
very good progress and responded well c previous PT Tx

Problem List:
1. constant dull aching, numbness and radiating pain c PS 7/10 on the R buttock that extends to the
posterior thigh Intermittent aching, radiating pain c PS 2-3/10 on the R buttock that extends to the
posterior thigh
2. Pt has ↓ AROM on trunk lat flexion, and hip flexiom
3. Fair tolerance in prolonged sitting and standing d/t pain.
4. (+) Gait deviation
5. (+) postural deviation
6. ms spasm on B piriformis
7. Tightness on of Hamstring
8. taut band on ® Lower back
9. gr 1 tenderness on (B) piriformis L>R

LTG(3x/wk for 12wks)


1. pt. will report an eliminated constant dull aching, numbness and radiating pain on the R buttock that
extends to the posterior thigh.
2. Pt will be able to eliminate tightness manifested by NROM on hip flexion and thoracolumbar lateral
flexion
3. To achieve N tolerance in sitting and standing
4. Pt will be able to exhibit and maintain proper posture and observe proper body mechanics
5. Pt will be able to perform N gait pattern

STG(3x/wk for 6wks)

1. Pt will report a decrease in pain by 2 increments in PS from 7/10 to 4/10


2. Pt will demonstate a decrease ms tightness manifested by an increase in ROM by 100 increments
towards (L/R) hip flexion and thoracolumbar lateral flexion
3. Pt will present an eliminated ms spasm on B piriformis , taut band on ® Lower back AND gr 1
tenderness on (B) piriformis L>R

P:

PT Mx

1. HMPX 15’ on B paralumbar, piriformis and gluteus


2. US X 1.25 w/cm2 on B paralumbar, piriformis and gluteus
3. Effleurage  MRT
4. Gentle stretching on B hamstring, piriformis and gluteus
5. Pt. education on proper body mechanics and proper posture to avoid complications and/or further
injury

HEP
1. Self stretching techniques on hamstring, gluteus ma, and piriformis x 30 SH x 2 reps
2. Observe PBM

PRECAUTION:
1. BP

Prepared By:

Gurtiza Joanna Eden

Lorma Colleges PT Intern ‘18