EVERYDAY PT

REHABILITATION MEDICINE AND PHYSICAL THERAPY DEPARTMENT

Mayon Ave.,San Quintin St., Naga City, Camarines Sur
INITIAL EVALUATION

Patient Info
Name: Zenaida Abella (Z.A.)
Age: 65
Sex: Female
Address: Camaligan CamarinesSur
Civil Status: Married
Handedness: Right
Occupation: House Wife
Religion: Roman Catholic
Referring MD: Dr. jesse Joson
Date of Referral: October 9, 2023
Date of I.E.: October 9, 2023
Dx: MPS (Myofascial pain syndrome)

SUBJECTIVE

C/C: “Makulug si sa may likod kang left ko na ear, garo igwang nag gagapang, then na sunod
nas si kulog kang sa side kangbreast ko sa left part. Si sa may likod ko man sa left side, garo
siya nag carcarmps tapos na baba ang kulog hanggang sa takyag ko”

PT Translation: Pt. feels sharp-shooting pain on the Ⓛ ear that goes down to the pt’s Ⓛ lateral
aspect of the breast. Pt also feels cramping pain from the Ⓛ postero-lateral aspect of the neck
down towards the pt’s Ⓛ shoulder and arm.

Pt. Goal: “mawara ang kulog sa may talinga ko and si kulog kang sa may likod kang liog ko”

PT Translation: Pt. wants to eliminate sharp-shooting pain on the Ⓛ ear and cramping pain on
the Ⓛ postero-lateral aspect of the neck

Precaution: HTN, DM
HPI

Informant: Ⓑ Pt and Daughter

Reliability: Good

Pt’s present condition started last year, September 2023 when the pt. felt a sharp-shooting
pain on the Ⓛ ear radiating down towards the pt’s Ⓛ lateral aspect of the breast with a pain
scale of 3/10, and cramping pain on the Ⓛ postero-lateral aspect of the neck that radiates down
towards the pt’s Ⓛ shoulder and Ⓛ arm with a pain scale of 3/10, aggravated during ADL’s and
over fatigue, alleviated at rest. Pain felt was on and off, and whenever pain was not present, pt.
Proceeds to do her ADL’s normally. After some time, the sharp-shooting pain and cramping pain
c̅ a pain scale of 3/10 increased to 5/10, then Pt. decided to have a check up through
Endoscopy at Bicol Access Centrum in September 2023. Pt. was assessed by Dra. Reyes and
the results were normal. Pt had also undergone various examinations such as MRI, X-ray, and
CT-Scan. Pt. had shown us the X-ray which was conducted on September 11, 2023 at
Plazamedica X-ray Clinic and was assessed by Dra. Marife reyes, with results of Cervical
Spondylosis and narrowed disc spaces on C4/C5, C5/c6 and C6/C7. Pt. also had an MRI on
September 19, 2023 at NICC Doctors Hospital and was assessed by Dr. Jesse Joson for the
pt’s spine. Results showed that, pt. has Degenerative spinal changes, Facet joint arthrosis on
l4/L5 and L5/S1. Pt. also had undergone CT-scan on October 2022 on CamarinesSur Provincial
Medical Center in Bula for pt’s Ⓛ ear sharp-shooting pain and was assessed by Dr, Perez,
results were normal after the assessment. P all the examinations, Pt was referred to everyday
PT for further assessment and treatment by Dr. Jesse Joson. On October 9, 2023, pt. Went to
Everyday PT, was assessed and a treatment session started.

Medications: Pt. has the ff. medications

Medication Dosage Frequency Indication Adverse Effects

Generalized
swelling, weight
gain, allergic
Cardipres/Carve reactions, chest
2.25 B.i.d (2x a day) HTN
dilol pain, dizziness,
lightheadedness,
pain, slow
heartbeat
Ancillary Procedures

Procedure Location Taken at Date Results

Xray Cervical spine Plazamedica September 11, Cervical

AP/Lat. X-ray Clinic 2023 Spondylosis,
Stenosis

MRI Whole Spine NICC Doctors September 19, Degenerative

Hospital 2023 Spinal Changes,
Facet joint
arthrosis

CT Scan Ⓛ Ear CamarinesSur October 2022 Normal

Provincial
Medical center

Endoscopy Ⓛ Ear Bicol Access September 2023 Normal

centrum

PMHx
● (+) HTN
● (+) DM
● (+) Breast Cancer on 2017
● (+) Hospitalization on 2017
● (+) Surgery on 2017 d/t breast cancer at ® breast
● (-) Allergies
● (-) Asthma

SHx
● Pt has an active lifestyle. Pt. does ADL’s such as gardening, washing dishes, cleaning
the house etc. on a daily basis. Pt. is also active in participating in Zumba and does
exercise.
● Pt. prefers eating fruits and vegetables with some meat and fish as a diet.
● Pt. does not smoke
● Pt. does not drink alcoholic beverages
FMHx

Name of Dse Father Mother

HTN + +

ASTHMA - +

OA - +

DM - -
Findings: Pt’s mother and father Ⓑ have hx of HTN, pt’s mother has hx Asthma and OA
Significance: Pt. is at risk of developing Asthma and OA

OBJECTIVE

V.S. (Vital Signs)

ā p̄ Location

BP (mmHg) 130/90 mmHg 130/80 mmhg Medial Antecubital

Fossa

PR (bpm) 90 bpm 94 bpm Index Finger

RR (cpm) 17 cpm 19 cpm Chest

Temperature 36.0° 36.0° Forehead

O.I
● Endomorph
● A/C/C (alert/coherent/cooperative)
● Ambulatory ṡ AD’s
● (+) Postural deviation (see P.A.)
● (+) Neck hump
 PALPATION

● Normothermic on all palpated areas of Ⓑ UEs

● (+) Nodules on Ⓑ Upper trapezius area
● (+) Taut bands on Ⓑ Upper trapezius area
● (+) Gr.1 tenderness on Ⓑ postero-latral aspect of the neck
● (-) Swelling on Ⓑ Upper trapezius
● (-) Edema on Ⓑ Upper trapezius
● (-) Crepitus on Ⓑ Upper trapezius
● (-) Muscle Spasms on Ⓑ Upper trapezius

Musculoskeletal Assessment

ROM (Range of Motion)

DIFFERENCE
L Ⓝ R
ARO ARO
End Feel
Ⓝ End
Motion PROM PROM Feel
M M

AROM PROM L R AROM PROM L L R R L R

Cervical
0°-10° 0°-35° 0°-49° 0°-51° 0°-50° 0°-40° 0°-39° 0°-16° 0°-1° 0°-10° Empty Firm Firm
Rotation

Cervical
lateral 0°-10° 0°-18° 0°-22° 0°-22° 0°-11° 0°-19° 0°-12° 0°-4° 0°-11° 0°-3° Empty Empty Firm
Flexion

DIFFERENCE
ARO Ⓝ End
Motion M
PROM Ⓝ End Feel
Fee
AROM PROM

Cervical 0°-10° 0°-5°

0°-30° 0°-35° 0°-40° Empty Firm
Flexion

Cervical 0°-20° 0°-15°

0°-30° 0°-35° 0°-50° Empty Firm
Extension
MMT (Manual Muscle Testing)

MMT Grade

L R

Bilat. Shoulder Flexion 4-/5 4-/5

Bilat. Shoulder Abduction 4-/5 4-/5

Cervical Lateral Flexion 4-/5 4-/5

Cervical Extension 4-/5

Cervical Rotation 4-/5 4-/5

Findings: Pt. has ↓ MMT Strength on Ⓛ and ® shoulder flexion and abduction, and cervical
mobility.
Significance: Pt. has weaknesses that will affect ADL’s such as carrying stuff, head and neck
mobility.

Special Test

TEST PROCEDURE FINDINGS SIGNIFICANCE

Jackson The patient rotates (-): Pt. has no indicated

Compression Test the head to one side. pressure on the
The examiner then - pain that radiates nerve roots thus is
carefully presses into the arm, negative to this test.
straight down on the indicating pressure
head. The test is on a nerve root
repeated with the
head rotated to the
other side

Feagins’s Test The patient stands (-): Pt. has no signs of

with the arm apprehension on the
abducted to 90° and face and has no
 the elbow extended - apprehension on presence of inferior
and resting on the top the patient’s face capsular laxity thus is
of the examiner’s negative for this test.
shoulder. The - presence of inferior
examiner’s hands are capsular laxity
clasped together over
the patient’s
humerus, between
the upper and middle
thirds. The examiner
pushes the humerus
down and forward

Postural Analysis

LANDMARK A/P VIEW LATERAL VIEW

Head Midline Forward head posture

Neck (+) Neck hump ↑ Kyphotic posture

Shoulder Ⓛ slightly lower than ® Protracted Scapula

Elbow ® elbow Slightly flexed

Spine Midline Innervated lumbar Lordosis

Hips ASIS and PSIS are leveled Normal

Knees Leveled Normal

 Ankle Medial and Lateral Malleoli are Normal
leveled

Outcome Measurement Tool

ADL/ Functional Assessment:

Self- Care Eating 7

Grooming 7

Bathing 7

Dressing-upper body 7

Dressing lower body 7

Toileting 7

Sphincter Control Bladder management 7

Bowel management 7

Mobility/Transfer Bed/chair 7

Toilet 7

Tub/shower 7

Locomotion Walk 7

Stairs 7

Findings: Pt. is independent in all aspects of the assessment.

Significance: Pt. will not have difficulty in ADLs.
ASSESSMENT

PT Impression

Pt is a 65 year old female presenting c̅ MPS c̅ a pain scale of 5/10 on Ⓛ postero-lateral

aspect of the neck, slight muscle weakness on shoulder flexion and abduction, cervical mobility
c̅ ↓ mobility on Ⓑ cervical rotation and lateral flexion, (+) postural deviation, (+) forward head
posture, ↑ Kyphotic neck posture, Ⓛ shoulder slightly lower than ®, ® Shoulder slightly
flexed. Pt. also has (+) nodules on Ⓑ Upper trapezius, (+) Taut bands on Ⓑ upper trapezius.

Rehab Potential/Prognosis

Pt. has good rehab potential 2° to minimal disability, complete independence in performing
ADL’s, ability to follow instructions c̅ willingness to participate in the plan of care.

Problem List

● Cramping pain on Ⓛ postero-lateral aspect of the neck and shoulder

● Sharp-shooting pain on Ⓛ ear down towards the Ⓛ lateral aspect of the breast
● (+) Nodules on Ⓑ upper Trapezius
● (+) Taut bands on Ⓑ upper Trapezius
● (+) Postural deviations; (+) forward head posture, (+) neck hump
● LOM on Cervical lateral flexion and Cervical rotation
● MMT weakness on Ⓑ Shoulder flexion and abduction, Cervical Mobility

LTG(3x/week, 10 months)

1. Eliminate cramping pain on Ⓛ postero-lateral aspect of the neck and shoulder within 3
weeks of treatment, avoiding fatigue and too much ADL’s to prevent recurrence.
2. Eliminate pain sharp-shooting pain on Ⓛ ear down towards the Ⓛ lateral aspect of the
breast within 3 weeks of treatment.
3. Eliminate Nodules on Ⓑ upper Trapezius.
4. Eliminate Taut bands on Ⓑ upper Trapezius
5. Correct postural deviations; straighten head posture, eliminate head hump within 3
weeks of treatment.
6. Normal ROM on Cervical lateral flexion and Cervical rotation within 4 weeks of
treatment.
7. Normal (5/5) strength of Ⓑ Shoulder flexion and abduction, Cervical Mobility within 4
weeks of treatment, maintain daily strengthening exercises.
STG (3x/week, 4 months)

● ↓ Cramping pain on Ⓛ postero-lateral aspect of the neck and shoulder from a pain scale
of 5/10 to 2/10 within 2 weeks of treatment.
● ↓ Sharp-shooting pain on Ⓛ ear down towards the Ⓛ lateral aspect of the breast from a
pain scale of 5/10 to 2/10 within 2 weeks of treatment.
● ↓ Nodules on Ⓑ upper Trapezius within 2 weeks of treatment.
● ↓ Taut bands on Ⓑ upper Trapezius within 2 weeks of treatment.
● To correct Postural deviations; ↓ Forward head posture, ↓ Neck hump within 3 weeks of
treatment
● ↑ ROM on Cervical lateral flexion, Cervical rotation, Cervical flexion, and Cervical
extension c̅ at least 5° of increment, within 2 weeks of treatment
● ↑ Strength of Ⓑ Shoulder flexion and abduction, Cervical Mobility from 4-/5 to 4+/5
within 3 weeks of treatment.

PLAN

PT Mx

1. TENS on painful areas of Ⓑ Upper trapezius x 15 mins

2. IRR on Ⓑ Upper Trapezius x 15 mins
3. US on Ⓑ Upper Trapezius x 5 mins each side
4. DKM on Ⓑ Upper Trapezius x 3 mins
5. Stretching of Bilat. Trapezius x 30 secs hold x 3 sets
6. Calliet exercises x 30 secs hold x 3 sets
7. Chin Tucks x 7 secs hold x 10 reps
8. Resistive shoulder retraction c̅ the use of green & yellow thera-tube x 7 secs hold x 10
reps

Suggested PT Mx

1. Wall sliding exercises Ⓑ shoulders while standing x 10 reps x 2 sets

2. PNF exercises with cones x 10 reps x 2 sets
3. Wand exercises, all planes to Ⓑ shoulders while standing x 10 reps x 2 sets
4. Bicep curls c̅ 3 lbs dumbbells Ⓑ shoulders while sitting/standing x 10 reps x 2 sets
5. Triceps curls c̅ 3 lbs dumbbells Ⓑ shoulders while sitting/standing x 10 reps x 2 sets
6. Neck lateral flexion on Ⓑ sides x 10 reps x 2 sets
7. PRE’s on Ⓑ UEs, all planes x 7 reps x 3 sets
8. Pelvic bridging x 7 secs hold x 3 sets
Home Exercise Program

1. Shoulder abduction exercises c̅ water bottles as substitute for dumbbells x 10 reps x 3

sets
2. Shoulder flexion exercises c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
3. Bicep curls c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
4. Triceps curls c̅ water bottles as substitute for dumbbells x 10 reps x 3 sets
5. Williams flexion (1 to 3) x 7 secs hold x 5 sets for each motion
6. Forearm pronation and supination on Ⓑ forearms c̅ water bottles as substitute for
dumbbells x 10 reps x 2 sets

Home Instruction Program

1. Pt and family education; pt’s condition, medication, preventing 2° impairments,

maintaining exercise and precautions during exercise.
2. Proper body mechanics given to pt; proper sitting, proper bed positioning, proper way of
getting up the bed and getting on the bed.

Donacao, Anton Lorenzo B.

USI - BSPT Intern Batch 2024