PLEASE HELP ME ANSWER IN COMPLETING MY INITIAL EVALUATION,..
PLEASE HELP ME ANSWER IN COMPLETING MY INITIAL EVALUATION,… PLEASE HELP ME ANSWER IN COMPLETING MY INITIAL EVALUATION, INFORMAATION IS SEEN BELOW GENERAL INFORMATION Patient’s name: I.P.K.Age: 35Gender: MaleAddress: Trancoville, Baguio CityHandedness: LeftOccupation: Tire mechanicReligion: Roman CatholicReferring Dr.: Dr. Melisa Garlan, Orthopedic DoctorReferring Unit: OPDRehab Dr.: Dr. Jannine Tabacuran, PhysiatristDate of Referral: February 20, 2022Date of Consultation: February 20, 2022Date of Initial Evaluation: February 20, 2022Diagnosis: (L)Cervical pain secondary to a herniated nucleus pulposus SUBJECTIVEC/C: “Masakit ang aking kaliwang leeg lalo na kapag ako ay nagsasara ng pinto ng sasakyan ko” P/S 8/10PT Translation: “My left neck is painful whenever I closed the door of my car P/S 8/10Patient’s goal: To be able to lessen the pain in (L) Side of my neck when I closed the door of my car. HISTORY OF PRESENT ILLNESSPresent condition started last February 16, 2022 when the px was fixing the car of his client. Px stated that he felt Tingling pain in his left-sided neck that radiated distally down his left arm to his thumb and index finger P/S 8/10. The px stated that he rested for an hour and felt a decrease in pain from 8/10 to 6/10. The px also took a pain reliver and felt a decrease in pain from P/S of 8/10 to 6/10. The following day, the px was bothered by the persistence of tingling pain on his (L) arm to his thumb and index finger. P/S OF 9/10. This prompted the px to consult the doctor at the Holistic Medical Clinic. Px was attended by Dr. Melisa Garlan, an Orthopedic doctor. The px was requested to undergo ancillary procedures (see ancillary procedures). Px was prescribed with medications (see medications). Px was advised to come back after 3 days for a follow-up checkup.February 20, 2022, px came back to see Dr. Garlan due to persistence of pain and difficulty reaching for objects and was referred to Dr. Tabacuran, a physiatrist at the Holistic Medical Clinic for further evaluation and PT tx. Ancillary Procedures:Ancillary ProceduresDateResultMRI February 17, 2022An MRI scan revealed a C5 disc herniation with C6 nerve root compression Present Medication:NameDosageIndicationIbuprofen 200mg qidInflammation & Pain Relief Family History:ConditionFatherMotherHTN/CAD+-Arthritis–Diabetes+-Cancer–Asthma-+Allergies-+ Past Medical and Surgical History: (+) prescription drug addiction(-) Asthma (-) Hypertension (-) Allergies Social and Environmental History: Type B personality Occasional alcoholic beverage drinker, 2 redhorse (stallion size: 330ml) a week; 104 bottles per year. OBJECTIVEVital Signs BEFORE TREATMENT DURING TREATMENT AFTER TREATMENTBP110/60110/80110/70HR/PR777878RR161816TEMPERATURE36°36.2°36.1°SPO298%99%97%Significance: For baseline purposes Ocular InspectionAmbulatory s ADA/C/C x4Mesomorph(-) Swelling (-) Wounds(-) Atrophy(-) Postural DeviationPalpationNormothermic on all exposed body partsNormotonic on all 4s(+) Tightness on (L) Shoulder(+) Grade II tenderness on (L) Shoulder(-) Taut band(-) Edema(-) Contractures(-) Subluxation(-) Nodules(-) Dislocation RANGE OF MOTION ( ANSWER THIS BY FILLING UP THE DIFFRENCE AND WHAT TYPE OF END FEEL )All motion of the body are WNL and pain free except for:MOTIONACTIVEPASSSIVENORMALDIFFERENCEEND FEELSHOULDER EXTENSION35°45°60 °° SHOULDER ABDUCTION125°150°180°° CERVICAL EXTENSION25°35°45°° CERVICAL FLEXION30°40°45°° CERVICAL LATERAL ROTATION45°55°60°° FOREARM SUPINATION FOREARM PRONATION WRIST FLEXION WRIST EXTENSION Findings:Significance: MANUAL MUSCLE TEST ( ANSWER THIS WHAT WOULD BE THE PATIENT MANUAL MUSCLE TH=EST BASED FROM THE CON DITON OF THE PATIENT , and say what would be the findings and significance)MUSCLESRIGHTLEFT CERVICAL FLEXION CERVICAL EXTENSION CERVICAL LATERAL ROTATION FOREARM SUPINATION FOREARM PRONATION SHOULDER EXTENSION SHOULDER ABDUCTION WRIST EXTENSION WRIST FLEXION Findings:Significance: GRIP STRENGTH TEST: ( answer this based from the condition of patient and what would be the significance and findings) Findings:Significance: Deep Tendon Reflex: ( answer this ) SPECIAL TEST: ( answer this ) PT IMPRESSION ( answer this ) PT PROGNOSIS: ( answer this ) REHAB PTENTIAL:( answer this ) PROBLEM LIST ( SHORT TERM AND LONG TERM ): ( answer this ) PLAN OF CARE: ( answer this ) Health Science Science Nursing RHM 4356
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