EMILIO AGUINALDO COLLEGE-CAVITE

Initial evaluation
GENERAL INFORMATION:
Pxs Initial: I. E.
Age: 38
Sex: Female
Address: Brgy. Mapusok, Mulawin, Baguio
Civil Status: Single
Handedness: (R)
Occupation: Attorney
Religion: Protestant
Nationality: Filipino
Referring Unit: ZARS Hospital
Referring MD: Dr. A
Rehab Unit: ZARS Rehab Unit
Rehab MD: Dr. P
Date of Consultation: May 29, 2016
Date of Referral: May 31, 2016
Date of IE: May 31, 2016
Dx: Psoriatic Arthritis
HISTORY OF PRESENT ILLNESS:
Present condition started ~6 months PTIE, last January 1, 2016, after the New
Years Eve. She experienced intermittent, dull, aching throbbing pain on lower
thoracic region and hip joint c PS 2/10. The pain lasted for 1 hour after Px started
stretching the affected structures. Px thought that it was just a result of hectic
preparation for the New Years Eve.
~5months PTIE, on February 1, 2016, Px noticed that the pain seems to be
worsened when Px gets up in the morning from PS 2/10 PS 5/10. Px took pain
reliever (see DHx), pain decreased to PS 2/10.
~3 months PTIE, on March 1, 2016, when Px was picking up a box ~1kgworth of files, Px experienced difficulty in bending over d/t stiffness of the neck PS
3/10. She thought that it was just normal wear and tear from years of running and
standing long periods in court. The pain subsided 1 hour after Px started stretching
the neck.
~1 months PTIE, increasingly intermittent, dull, aching throbbing pain
persisted, PS 3/10 PS 7/10 on lower thoracic region and hip joint, but on May 20,
2016 Px felt that the pain PS 7/10 is unrelieved by rest and stretching lessen the
pain. Px took pain reliever (see meds taken) and noticed a of pain PS4/10. Px also
noticed nail changes starting from fingers then to toes.
~1 week PTIE, px experienced malaise and mild anorexia and noticed
swelling on posterior neck.
1 day PTIE, May 29, 2016, during an attempt to pick up pxs ballpen, severe
pain on lower thoracic region and hip joint was experienced (PS 3/10 PS 9/10) on

lower thoracic region and hip joint;. This prompted the px to seek medical tx; was
accompanied to ZARS Hospital and was requested to undergo X-Ray and Laboratory
Procedures (See Ancillary Procedures). Px was diagnosed c Psoriatic arthritis and
was prescribed pain reliever and same medication to pxs mild scalp psoriasis (see
present meds).
At present, Dr. A then refer px to Dr. P of the rehab unit of the same hospital
to undergo PT evaluation. Px still complains of dull, throbbing pain on the lower
thoracic region and hip joint (PS 5/10); also neck stiffness. Pt is independent c
moderate difficulty in doing activities such as sleeping, forward flexion of the both
lumbar ang cervical spine.
ANCILLARY PROCEDURE:
Date
MD
X-ray of
May 29, 2016 Dr. A
cervical
spine
(lateral
view)
X-ray of
May 29, 2016 Dr. A
lumbar
spine (A/P
view)

ESR
RF
HLA-B27
test

May 29, 2016

May 29, 2016
May 29, 2016

Dr. A
Dr. A
Dr. A

Findings
Syndesmophytes at the
C2-3 and C6-7 levels,
with zygapophyseal
joint fusion

Significance
(+) psoriatic arthritis
type: spondylitis

3 pinal fusion;
Syndesmophytes
taking place along the
enthesis of the IVD;
Irregularity and
sclerosis of sacroiliac
joint
ESR = 30 mm/hr.
(-) RF
(+)HLA-B27

(+) psoriatic arthritis

type: spondylitis;
(+) unilateral
sacroiliitis

Present Meds:
Name of Drug
Dosage/Frequency
Acetaminophen 650 mg 4 6 times
(Tylenol)
a day

Indications
Mild to moderate
pain and fever.

Neutrogena
T/Gel

Depending on
severity

to avoid severity of
mild scalp psoriasis

DHx:
Name of Drug
Ibuprofen
(Advil)

Dosage/Frequency
200 400 mg every
4 6 hrs

Neutrogena
T/Gel

Depending on
severity

Indications
Symptomatic relief
of minor pain,
inflammation, fever
or arthritis
to avoid severity of
mild scalp psoriasis

(+) inflammation
(-) RA
(+)
spondyloarthropathy
Side Effects
Does not cause GI
upset or bleeding.
Rush, occasionally c
fever
none

Side Effects
Headache, fatigue,
nervousness, rash
none

PMHx:
(+) Hospitalization
(-) mild scalp psoriasis
(-) Htn
(-) trauma
(-) DM
FMHx:
OA
DM
Htn
RA
Psoriasis

Maternal
(+)
(-)
(-)
(-)
(-)

Paternal
(-)
(-)
(-)
(-)
(+)

PSEHx:
Attorney: works 7hrs every day/ 5 days a week; work requires prolonged
standing and sitting
Type A personality
Non cigarette smoker
Non-alcohol drinker
Caffeine drinker
Hobbies: jogging, swimming, reading
Financially stable
Lives c her 2 daughters in a 2-storey house
Px bedroom located on the 2nd floor; distance of bedroom sala ~ 20 steps;
bedroom kitchen ~ 30 steps; bedroom bathroom~10 steps; bedroom
entrance door ~ 25 steps; bedroom garage ~ 30 steps; has 1 flight of stairs
c 10 steps; Marmol ceramic tile surfaces and handrails on B sides.
Mode of transportation: own car
S:
C/C: Pabalik-balik yung pagkirot ng likod ko lalo pag yumuyuko. Yung sakit
lumalala sa umaga o pag hindi ko ikinilos. Na-feel ko rin na nagka-stiff-neck ako at
may maga.
PT Translation: Px c/o intermittent, dull, aching throbbing pain on lower thoracic
region and hip (9/10; 10= worse possible pain, 0= no pain), aggravated upon
inactivity; neck stiffness; (+) inflammation.
Pxs Goal: Gusto kong mawala at wag pang lumala yung sakit, bumalik sa dati at
makakilos ng maayos.
O:
VITAL SIGNS
BP

a Tx
110/80 mmHg

During Tx
120/80 mmHg

p Tx
110/80 mmHg

RR
16 cpm
18 cpm
PR
70 bpm
73bpm
TEMP
36.5o
36.5 o
Findings: VS a, during and p are WNL
Significance: For baseline purposes and precautions to tx.

18 cpm
73bpm
36.5 o

OCULAR INSPECTION:
Non-ambulatory
Alert/Coherent/Cooperative
Mesomorph
(+) pain distress
(+) mild swelling on posterior neck
(+) mild swelling on PSIS
(+) generalized fatigue
(+) onycholysis on both fingers and toes
(+) mild erythema on scalp
PALPATION:
Normotonic on B UE/LE
Normothermic on all other exposed body parts except lower back and
posterior neck, hyperthermic
(+) Grade 2 tenderness on posterior neck
(+) Grade 2 tenderness on PSIS
(+) Ms guarding on lumbar and hip flexion
ROM:
All major joints of WNL actively and passively done pain-free except for the ff:
R Ankle
N
AROM
PROM
END-FEEL
DIFFERENCE
AROM
PROM
Cervical
0 20
05
05
Empty
15
15
Flexion
Lumbar
0 50
0 15
0 20
Empty
35
30
Flexion
Hip
0 20
05
08
Empty
15
12
Flexion
Findings: Px has LOM on forward flexion of lumbar and cervical spne
Significance: LOM d/t neck stiffness & intermittent, dull, aching throbbing pain on
lower thoracic region and hip joint may affect ADL of the px; tx should include
modalities that will decrease the stiffness & pain

MMT:
All major mm groups of (B) UE/LE are grossly assessed graded 5/5 except for the ff:
MUSCLE GROUP
FINDING
Cervical flexion
Weak and painful
Trunk flexion
Weak and painful

 hip flexion
Weak and painful
Note: break test was used
Findings: Px has decrease in strength on cervical and trunk flexion.
Significance: Px does not want resistance to be applied d/t pain. Tx should include
modalities addressing the pain on posterior neck, lower thoracic region and hip
and exercises for the leg mms
Note: MMT should be reassessed when pain is eliminated.
SPECIAL TEST:
Special test
Procedure
Schobers
mark at the level of the PSIS. PT
test
then places one finger 5cm
below this mark and another
finger at about 10cm above this
mark. The px is then instructed
to touch toes.

Response
Significance
Distance = (+)limitation of
50 cm
lumbar flexion

POSTURAL ANALYSIS:
Px was assessed on standing on both AP and lateral view inside walker.
A/P view
lateral view
Midline
Head
Neutral
Neutral
Shoulder
Neutral
Neutral
Scapula
Neutral
Neutral
Elbow
Neutral
Neutral
Hand
Neutral
Midline
Back
Neutral
Neutral
Pelvis
Neutral
Neutral
Hips
Slightly extended
Neutral
Knees
Neutral
Neutral
Ankle
Neutral
Findings: (-) postural deviation
GAIT ANALYSIS:
(-) gait devation
Sensory Testing:
Sensory assessment was done
Superficial Somatic Sensation
o Superficial pain pin
o Light touch brush
o Deep pressure thumb
Findings: Px has 100% intact superficial sensation
Significance: For tx precaution in using modalities.
ANTHROPOMETRIC MEASUREMENT:
ALL:
Location
L
umbilicus to medial
86

R
86

Difference
0

malleolus of each
foot
Findings: px (-) functional leg length discrepancy
TLL:
Location
L
ASIS
to
medial
malleolus of each
80
foot
Findings: px has (-) true leg length discrepancy

Difference

80

ADL Assessment:
BADLs

Status
Modified Independent with moderate
LE Dressing
difficulty
Ambulation
Independent
Modified Independent with moderate
Rising from chair
difficulty
Modified Independent with moderate
Transfer
difficulty
Modified Independent with moderate
Hygiene
difficulty
Findings: Px is independent and has moderate difficulty in performing ADLs such as
LE dressing, rising from a chair, transfer, and hygiene.
Sig: Px will have difficulty in performing efficiently at work and at home
FUNCTIONAL ANALYSIS:
Balance
Tolerance
Short Sitting
Fair
12 mins POOR
Long Sitting
Poor
3 mins FAIR
Findings: Px has fair balance tolerance during short sitting and poor balance
tolerance during long sitting d/t pain.
Sig: Px may need to rest after the tolerated time and avoid prolonged sitting
activities.

A:
PT IMPRESSION:
Px was diagnosed c psoriatic arthritis c presence of dull, throbbing pain on
lower thoracic region and R hip jt (PS 7/10, neck stiffness), grade 2 tenderness,
mild erythema causing the pt moderate difficulty in performing ADLs such as LE
dressing rising from a chair, transfer and hygiene at work and at home
REHAB POTENTIAL:
Px has a fair-good prognosis in improving condtion d/t the ff reasons:
1.
Pt has no other complications such as fx & mm atrophy.
2.
Pt is a 38 y/o female attorney
3.
Pt is a non-smoker and non-alcoholic drinker
4.
Pt is (-) on HTN & DM.

5.
6.

Pt is motivated, cooperative and willing to attend PT sessions to

improve her condition.
Pt is financially stable.

PROBLEM LIST:
1.
(+) mild inflammation on posterior neck
2.
(+) mild innflammation on R PSIS
3.
(+) generalized fatigue
4.
(+) onycholysis on both fingers and toes
5.
(+) mild erythema on scalp
6.
(+) Grade2 tenderness on posterior neck
7.
(+) Grade2 tenderness on R PSIS
8.
(+) muscle guarding on lumbar and R hip flexion
9.
LOM on forward flexion of lumbar and cervical spines
10.
in strength in cervical and trunk flexion
11.
(+) antalgic gait on R LE
LTG:
In 3mos duration, 4 tx sesion/wk:
1.
To attain highest functional outcome
2.
To reduce or avoid the risk of having secondary complications to injury
such as deconditioning, mm atrophy and deformities that may come
along if left unmanaged
3.
Independent c minimal difficulty in performing ADLs at work and at
home
4.
Eliminate dull, throbbing pain on thoracic region and neck stiffness
5.
To perform minimal difficulty in performing LE dressing, rising from a
chair, transfer and hygiene
6.
Eliminate mild erythema on scalp
7.
Eliminate inflammation on posterior neck and R PSIS
STG:
In 1month duration, 4 tx session/wk:
1.
To mm strength of cervical flexors(3/55/5)
2.
To ROM of lumbar and cervical flexion
3.
To tenderness on posterior neck from Gr2 to normal
4.
To tenderness on R PSIS from Gr2 to normal
5.
Demonstrate proper posture
6.
mm strength of trunk flexors(2/54/5 or better)
7.
Perform ADLs with minimal difficulty
P:
Tx sessions (4x / wk)
1. Educate the patient for proper positioning of the body to prevent contracture
formation.
2. AAROMEsAROMEs on (B) SCM & trunk flexors x 10 reps x 3 sets x od to
ROM maintain available ROM
3. Cont. US 1MHz 1.5W/cm2 5' on lumbar region avoid spine
4. HMP 70-75C 45-60' on lumbar region
5. Vapocoolant spray 2-3 sprays 5 secs interval on lumbar region

6. Aquatic therapy to mm spasm & joint pain.

HEP
1.
2.
3.
4.

Educate the px about his condition & precautions

Always take meds on time
Lifestyle modification of px & proper diet
Self-stretching exercise on lumbar region 3 sets daily to maintain tissue
extensibility
5. Always maintain proper posture & proper body mechanics.

_____________________
Altar, Jan Paolo x
EAC-C PT Student Batch2018
_____________________
Ramos, Cristine Joy B.
EAC-C PT Student Batch2018
_____________________
Vergara, Shekinah M.
EAC-C PT Student Batch2018
_____________________
Zaldarriaga, Raphaela Y.
EAC-C PT Student Batch2018

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