LOW BACK PAIN

General Info

Px Name : Aguinaldo Mabini

Address : San Pablo City
Sex :Female
Age :49
Civil Status :Married
Handedness :R
Occupation : Factory Worker
Reffering Unit : OPD
Refferal Dr. : Dr. A
Date of Refferal : July 2, 2019
Date of IE :July 5, 2019
Dx : Low Back Pain

S: C/C sharp shooting pain from low back area c (PS:9/10) Felt upon rising from bed and relieve by
sitting.

HPI:
Present condition started last october 18,2019,when Px slipped in their house and landed on her
buttocks upon impact on the ground Px felt pain c (PS:9/10) but did not consulted any medical advice.
Px took oral medicine(ibuprofen) to relieve the pain and went to massage parlor but persistence of pain
didn’t subside. This prompted the Px to seek medical help. Px consulted Dr. A of SPCMC and she under-
went to medical examination and was Dx c Low back pain. Px was then reffered to PT rehab for further
eval and Mx.

PMHx:
(-)DM (-)Cardiac dse
(-)HTN (-) Asthma
FMHx:
Maternal paternal
arthritis + +
DM - -
Cardiac Dse - -
HTN - -

SHx : + Coffee drinker 2-3 per day

+ Alcohol drinker(ocassional)
- Smoker

Home situation: Px lives in a bungalow type of house c her husband and two sons
O: VS
BP : 110/80 mmHg PR: 68 bpm
RR: 15 cpm Temp: A febrile

OI: A/C/C x3
mesomorph
(-) postural deviation
(-) swelling

Palpation:
Normothermic on all exposed body parts
Normotonic on all 4s
(+) Nodules on (B) paralumbar
(+) Ms spasm on (B) paralumbar
(+) grade 1 tenderness on paralumbar area

ROM: All joints of (B) UE and LE are WNL actively and passively taken pain free c (N) endfeel excet for

N A P D-A D-P Endfeel

(L) Hip flexion 0-120° 0-80° 0-90° 40° 30° empty

Findings: LOM of hip

MMT: All muscles (B) UE and LE are grossly graded 5/5 except for hip flexors 4/5 and abdominals 4/5

Findings: Muscle weakness d/t pain

Neuro eval:

A. Sensory Assesment
STD : Pin for pain, brush for light touch and thumb for deep pressure

Findings : 100% sensory intact on all exposed body parts.

 B. DTR

significance: Normoreflexive on all 4s

Special test:

(+) 90-90 SLR

indication: Hamstring tightness
(+) Thomas Test
indication : iliopsoas tightness

A: Problem list
1.Moderate difficulty in doing bed mobility esp. in supine – long sitting – standing
2. (M) weakness of (psoas major) and abdominals
3. LOM of hip Flexion
4. (M) spasm on (B) Paralumbar
5. Nodules on (B) Paralumbar
6. Grade 1 tenderness on paralumbar
7. Sharp shooting pain on paralumbar c PS: 9/10

STG( 3 weeks)

1. To decrease diff. in ADL especially in bed mobility (supine-longsitting- standing)

2. To improve Ms. Strength of (L) LE and abdominals from 4/5 to 5/5
3. To increase ROM of (L) Hip flexion c 10 increments
4. To decrease Ms. Spasm on paralumbar area
5. To decrease nodules on paralumbar area
6. To decrease tenderness on paralumbar area
7. To decrease sharp shooting pain on paralumbar area from 9/10 to 4/10 PS
LTG (1mos)
1. To eliminate diff. in doing ADLs
2. To maintain (N) ms. Strength of hip flexors and abdominal ms.
3. To achieve full ROM of hip flexion
4. To eliminate Ms. Spasm on paralumbar area
5. To eliminate nodules on paralumbar area
6. To eliminate tenderness on paralumbar area
7. To eliminate sharp shooting pain on paralumbar area

HI: Awareness of proper body mechanics