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EMILIO AGUINALDO COLLEGE-CAVITEInitial evaluation

GENERAL INFORMATION:Pxs Initial: I. E.Age: 38

Sex: FemaleAddress: Brgy. Mapuso! Mula"in! Baguio#ivil Status: Single$andedness: %&'())upation: Attorney&eligion: Protestant*ationality: Filipino&e+erring ,nit: -A&S $ospital&e+erring M: r. A&e/a0 ,nit: -A&S &e/a0 ,nit&e/a0 M: r. Pate o+ #onsultation: May 12! 145

ate o+ &e+erral: May 34! 145ate o+ IE: May 34! 145x: Psoriati) Art/ritis

HISTORY OF PRESENT ILLNESS:Present )ondition started 65 mont/s P7IE! last anuary 4! 145! a+ter t/e *e"

9ears Eve. S/e experien)ed intermittent! dull! a)/ing t/ro00ing pain on lo"ert/ora)i) region and /ip ;oint ) PS 1mont/s P7IE! on Fe0ruary 4! 145! Px noti)ed t/at t/e pain seems to 0e"orsened "/en Px gets up in t/e morning +rom PS 1

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lo"er t/ora)i) region and /ip ;ointG. 7/is prompted t/e px to see medi)al txG "asa))ompanied to -A&S $ospital and "as reHuested to undergo ?&ay and Ja0oratoryPro)edures %See An)illary Pro)edures'. Px "as diagnosed ) Psoriati) art/ritis and"as pres)ri0ed pain reliever and same medi)ation to pxs mild s)alp psoriasis %seepresent meds'.

At present! r. A t/en re+er px to r. P o+ t/e re/a0 unit o+ t/e same /ospitalto undergo P7 evaluation. Px still )omplains o+ dull! t/ro00ing pain on t/e lo"ert/ora)i) region and /ip ;oint %PS >

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PMHx:%' $ospitaliLation%?' mild s)alp psoriasis%?' $tn%?' trauma%?' M

FMHx:Maternal Paternal

(A %' %?'M %?' %?'$tn %?' %?'&A %?' %?'Psoriasis %?' %'

PSEHx:

Attorney: "ors D/rs every day< > days a "eeG "or reHuires prolonged

standing and sitting 7ype A personality

*on )igarette smoer

*on?al)o/ol driner

#a=eine driner

$o00ies: ;ogging! s"imming! reading

Finan)ially sta0le

Jives ) /er 1 daug/ters in a 1?storey /ouse

Px 0edroom lo)ated on t/e 1ndKoorG distan)e o+ 0edroom R sala 6 1 stepsG0edroom R it)/en 6 3 stepsG 0edroom R 0at/room64 stepsG 0edroom Rentran)e door 6 1> stepsG 0edroomR garage 6 3 stepsG /as 4 Kig/t o+ stairs

) 4 stepsG Marmol )erami) tile sur+a)es and /andrails on B sides. Mode o+ transportation: o"n )ar

S :C/C: Pa0ali?0ali yung pagirot ng liod o lalo pag yumuyuo. 9ung saitlumalala sa umaga o pag /indi o iinilos. *a?+eel o rin na naga?sti=?ne) ao atmay maga.C

PT Transat!"n:Px )

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&& 45 )pm 48 )pm 48 )pmP& D 0pm D30pm D30pm

7EMP 35.>o 35.>o 35.>o

Findings: NS a! during and p are T*JSignifcance: For 0aseline purposes and pre)autions to tx.

OCULAR INSPECTION: *on?am0ulatory

Alert 4> 1 Empty 3> 3

* H!+Fex!"n

1 > 8 Empty 4> 41

Findings:Px /as J(M on +or"ard Kexion o+ lum0ar and )ervi)al spneSignifcance: J(M d

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* !+ ,ex!"n Tea and pain+ulNote: 0rea test "as usedFindings:Px /asde)rease in strengt/ on )ervi)al and trun Kexion.Signifcance:Px does not "ant resistan)e to 0e applied d)m0elo" t/is mar and anot/er@nger at a0out 4)m a0ove t/ismar. 7/e px is t/en instru)tedto tou)/ toes.

istan)e O> )m

%'limitation o+lum0ar Kexion

POSTURAL ANALYSIS:Px "as assessed on standing on 0ot/ AP and lateral vie" inside "aler.A

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malleolus o+ ea)/+ootFindings: px %?' +un)tional leg lengt/ dis)repan)y

TLL:Jo)ation J & i=eren)e

ASIS to medialmalleolus o+ ea)/+oot

8 8

Findings: px /as %?' true leg lengt/ dis)repan)y

ADL Assess(ent:0ADLs Stat's

JE ressingModi@ed Independent "it/ moderate

di)ultyAm0ulation Independent

&ising +rom )/airModi@ed Independent "it/ moderate

di)ulty7rans+er

Modi@ed Independent "it/ moderatedi)ulty

$ygieneModi@ed Independent "it/ moderate

di)ultyFindings: Px is independent and /as moderate di)ulty in per+orming AJs su)/ asJE dressing! rising +rom a )/air! trans+er! and /ygiene.Sig: Px "ill /ave di)ulty in per+orming e)iently at "or and at /ome

FUNCTIONAL ANALYSIS:

0aan&e T"eran&eS/ort Sitting Fair 41 mins P((&

Jong Sitting Poor 3 mins FAI&Findings: Px /as +air 0alan)e toleran)e during s/ort sitting and poor 0alan)e

toleran)e during long sitting d

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>. Pt is motivated! )ooperative and "illing to attend P7 sessions toimprove /er )ondition.

5. Pt is @nan)ially sta0le.

PRO0LEM LIST:4. %' mild inKammation on posterior ne)

1. %' mild innKammation on & PSIS3. %' generaliLed +atigue. %' ony)/olysis on 0ot/ @ngers and toes>. %' mild eryt/ema on s)alp5. %' Qrade1 tenderness on posterior ne)D. %' Qrade1 tenderness on & PSIS8. %' mus)le guarding on lum0ar and & /ip Kexion2. J(M on +or"ard Kexion o+ lum0ar and )ervi)al spines10. in strengt/ in )ervi)al and trun Kexion44. %' antalgi) gait on & JE

LTG:

In 3mos duration! tx sesion. 7o per+orm minimal di)ulty in per+orming JE dressing! rising +rom a

)/air! trans+er and /ygiene5. Eliminate mild eryt/ema on s)alpD. Eliminate inKammation on posterior ne) and & PSIS

STG:In 4mont/ duration! tx session

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5. AHuati) t/erapy to mm spasm U ;oint pain.

HEP4. Edu)ate t/e px a0out /is )ondition U pre)autions1. Al"ays tae meds on time3. Ji+estyle modi@)ation o+ px U proper diet

. Sel+?stret)/ing exer)ise on lum0ar region Z 3 sets daily to maintain tissueextensi0ility

>. Al"ays maintain proper posture U proper 0ody me)/ani)s.

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