- Name: Mr.

Bun Heab
- ID: BSP220013 CLINICAL REASONING FORM B
- Khmer Friendship Hospital

This is to be completed after the patient physical assessment and treatment.

1. Describe the patient (age, gender, occupation, brief history of main

complaint, relevant past history if any)

-Ms. Sok Sotheary in the ages of 55years old.

She works as grocery store and living in Phnom Penh.
She complain tightness and sharp pain on the right of
lumbar 6/10 through ankle 5/10 cause by carry the
goods about 25 Kg 3days ago. She had pain killer and
the pain is down 3/10 only about 3hours.
After that, she worry about her health and decided to
come to get Physiotherapy service at Khmer Friendship
Hospital.

2. BODY CHART & INTERPRETATION

a. Complete the body chart and clearly label each symptom location
(VAS, associated symptoms, relationship)

- Tightness, sharp pain 6/10 during standing 5min. Pain 5/10 in sitting 5min
- Pain going down 3/10 when relaxing 5minutes.

3. INTERPRETATION OF THE PHYSICAL EXAMINATION

3.1 Which specific physical examination findings are related
with the patient’s complaints/functional limitations?
Active (Cm)
- AROM: LxFlex 65
LxExt 70
RSFlex 70
LSFlex 65
- Neurological Exam: Motor: Down L3-L4, L4-L5 (Compared to healthy side)
- Sensory: Down

3.2 What medical or radiological investigations have been carried out?

- X-Ray and MRI : No
 What are the main findings and are they relevant to the patient’s
disorder?

- No

Will the radiological findings influence your treatment

plan? State your reason.
- If 3-5 times not better, will requesting to discus with doctor to MRI
to avoid bad things.

4. ANALYSIS OF THE DISORDER

4.1 What is the patient’s diagnosis?

O - Radiculopathy Nerve Root Compression L3-L4, L4-L5

4.2 What is the expected prognosis?

- That is Good

State your reasons.

- After objective examination, she feel sharp pain P1 6/10 in 5 minutes and P2
5/10 in 5minutes.When relax p1 and p2 3/10. I expected that treating may better.

4.3 List the patient’s problem list (Max 3).

- Neurological Test (+) (L3-L4, L4-L5)

- Pain 6/10 when lumbar extension
- Pain 5/10 when sitting and standing

4.4 List your STG and LTG for this patient (patient centered approach) and
the time frame to achieve them.

- STG: - Reduce pain P1:6/10 to 4/10 (1week),

P2: 5/10 to 3/10 (1week)
- Increase ROM Lumbar Flex 70Cm to 55Cm (2weeks)
- LxExt 70Cm to 55Cm (2weeks)
- RSFlex 70Cm to 50Cm (2weeks)
- LSFlex 65Cm to 50Cm (2weeks)

- LTG: - Ability to move her lumbar, sit and walk more easily without (6-12weeks)
5. MANAGEMENT AND EVALUATION

5.1 What is your treatment for Day 1?

- Soft tissue technique (5-10minutes)

- Decompression L3-L4, L4-L5 in Flexion and RSF 60 moment 3sets
- Left Rotation L3-L4, L4-L5 60 moment 3sets
- Revere Lateral Flex L3-L4, L4-L5 60 moment 3sets

5.2 What asterisk signs would you use to evaluate your treatment
outcome? (you may include outcome measures)

- Reduce pain (Pain Scale)

- Soft tissue release (Muscle length and compare with healthy side)
- Improved ROM (Matter)

5.3 List your plan for the next session assuming that the patient is
a) better

- Observation about treatment with the same technique and add more exercises.

b) same

- Re-evaluation the assessment and add more exercises.

c) worse

- Re-evaluation and change the technique with according to Physical Examination.