12

INITIAL EVALUATION
Pt Initials: A. B.
Age: 35 y/o
Sex: Male
Address: San Vicente, Tarlac City
Civil Status: Married
Handedness: (R)
Occupation: Farmer
Referring Unit: OPD
Referring MD: Dr. Quirino
Rehab MD: Dr. Domingo
Date of Referral: October 8, 2014
Date of Consultation: October 9, 2014
Date of IE: October 9, 2014

HPI:

Present condition started 1 year PTC, when pt experienced heaviness and tolerable
pain in the right shoulder 5/10. Patient noted that his right shoulder was hit by a
baseball. Patient usually experienced pain whenever he attempts to comb his hair
and reach his back.

At present patient complains of intermittent acute, sharp, localized pain on the right
shoulder graded 8/10 without signs of inflammation. Due to the progressing pain,
patient decided to go to the hospital for check-up and further evaluation.

S: c/o intermittent acute, sharp, localized pain and LOM (8/10) on the right shoulder.
O:
VS:
BP a: 130/80 during: 130/80 p: 120/70
HR 70 bpm
RR 20 cpm
Temp 37 C

Palpation:
Normothermic on all exposed body parts
(+) Tenderness on (R) shoulder grade 1
(+) muscle spasm on R shoulder
(+) nodules on superior medial border of scapula
(-) abnormal bumps

ROM:
All joints of (B) UE/LE are WNL on all planes of motion except the ff.:
Joint Motion AROM PROM end feel

R sh flexion 0-75 0-98 Empty

R sh ER 0-22 0-30 Empty
R sh abd 0-110 0-170 Empty
R sh IR 0-60 0-70 Empty

MMT:
All major muscle groups of (B) UE/LE are graded 5/5 except the ff:
o R sh flexor 3+
o R sh ER 3+
o R sh abd 3+
o R sh IR 3+

Special Tests:
(+) Apley scratch test
(+) Empty can test
(-) Speed test
(-) Load and shift test
(-) Hawkins Kennedy test
(-) Yergason Test

ADL Assessment:
Patient is independent in all aspects of ADLs except:
o Dressing
o Grooming
o Reaching overhead

Instructions:
1. Analyze the case given.
2. Give the PT impression.
3. Discuss the medical condition based on the given case.
4. Identify the problem list.
5. Formulate the STG and LTG.
6. Formulate the treatment plan.