MAKE YOUR OWN INITIAL EVALUATION SAMPLE CASE DESCRIPTION IS SEEN…

Question Answered step-by-step MAKE YOUR OWN INITIAL EVALUATION SAMPLE CASE DESCRIPTION IS SEEN… MAKE YOUR OWN INITIAL EVALUATION SAMPLE CASE DESCRIPTION IS SEEN BELOW  YOU MAY USED IT IN COMPLETING THE NEEDED INFORMATION  PATIENT NAME:AGE:DX. HPIPAST MEDICAL HISTORYPERSONAL AND SOCIA; HX. VITAL SIGN (BEFORE AND AFTER)OCCULAR INSPECTION RANGE OF MOTION MANUAL MUSCLE TESTING SPECIAL TEST: NEUROLOGICAL ASSESSMENT :DEEP TENDON REFLEX:MUEROLOGICAL ASSESSMENT : SENSORY TESTINGGRIP STRENGTH PT IMPRESSIONPT PROGNOSISREHAB POTENTIAL PROBLEM LIST ( SHORT TERM AND LONG TERM) PLAN OF CARE   PLEASE HELP ME ANSWER THIS I AM APHYSICAL THERAPY STUDENT AND I FIND HARD TIME DOING THIS PLEASEEEE     CASE DESCRIPTION A 35-year-old male tire mechanic was referred to physical therapy by his primary care physician with a diagnosis of cervical pain secondary to a herniated nucleus pulposus. The onset of pain began two days prior to physical therapy evaluation when he experienced an intense pinch in his neck after closing his car door. He went to the emergency room immediately following the incident due to severe pain. An MRI scan revealed a C5 disc herniation with C6 nerve root compression. He was prescribed Percocet and physical therapy for pain management. He had a history of prescription drug addiction and was hesitant to comply with prescribed medication because of fear of relapse. He reported he took one Percocet in the past 48 hours which resulted in moderate pain relief. He sustained a right brachial plexus injury during birth that resulted in right upper extremity range of motion and strength deficits. He had no concerns with these deficits as he could complete all functional tasks independently. His primary complaint was left-sided neck pain that radiated distally down his left arm to his thumb and index finger. He was left-hand dominant. He was placed on driving restrictions while taking medication, as well as work and 15-pound lifting restrictions. He stated his symptoms generally increased over the course of the day and he had difficulty getting to and staying asleep at night. The patient’s 5 goals were to decrease pain, increase cervical mobility, decrease sleep disturbances, and return to full-time work duties. The patient completed the Neck Disability Index (NDI), a self-report measure to assess his perceived level of disability and the impact on daily activities.13 He scored 46% disability which was considered moderate disability. The test-retest reliability of the NDI has been reported to be moderate in patients with CR.14 Pain was reported at 9/10 (0=no pain, 10=worst pain possible). The patient did not present with any red flags based on history so a physical examination followed. Examination The physical examination began with a postural assessment which revealed a forward head and elevated and protracted shoulders. A modified vertebral artery test was completed prior to the physical assessment. In a seated position, the patient extended and rotated his head maximally to the right for 10 seconds, returned to neutral for 10 seconds, and then extended and rotated his head to the left as tolerated for 10 seconds.15 The patient did not experience any symptoms associated with vertebral artery occlusion. Cervical active range of motion (ROM) was measured over the course of treatment, using a bubble inclinometer as described by Norkin and White16 (Table 1). 6 Table 1. Cervical active range of motion findings. Initial Evaluation Week 2/Visit 4 Week 3/Visit 7 Week 4/ Visit 12 (Discharge) Flexion 50°, pain-free 54°, pain-free 53°, pain-free 54°, pain-free Extension 13°, pain throughout 38°, pain at end range 49°, pain-free 50°, pain-free Right Sidebend 47°, pain-free 48°, pain-free 50°, pain-free 49°, pain-free Left Sidebend 22°, pain throughout 41°, pain at end range 49°, pain-free 48°, pain-free Right Rotation 52°, pain-free 58°, pain-free 56°, pain-free 58°, pain-free Left Rotation 26°, pain throughout 43°, pain at end range 53°, pain-free 55°, pain-free Bilateral upper extremity active ROM was assessed in a supine position as described by Norkin and White.16 Deficits were noted in right shoulder flexion and abduction while all other motions were within functional limits and pain free bilaterally. No formal measurements were taken. Bilateral upper extremity gross manual muscle testing was performed in a seated position as described by Berryman Reese.17 Strength deficits were noted in right shoulder flexion and abduction as well as left elbow flexion and wrist extension. Right shoulder flexion and abduction were graded 3/5 (0=no muscle contraction, 5=able to hold against maximal resistance.) Left elbow flexion and wrist extension were graded 4-/5. Grip strength was assessed using a hand dynamometer and revealed strength within 15 pounds bilaterally. Cervical strength was not assessed due to patient intolerance. Spurling compression test was performed with the patient in a seated position. The patient’s neck was positioned in extension with his head rotated to the left while an axial load was placed on the spine by applying a downward pressure through the patient’s head. Spurling compression test was positive as 7 the patient experienced a reproduction of radicular symptoms into his distal left upper extremity.18 According to Tong et al,19 the test is highly specific (93%) for a diagnosis of CR, with low sensitivity (30%). The distraction test was performed in a seated position. The clinician placed one hand under the patient’s chin and the other around the occiput then slowly applied an upward force.2 The distraction test was positive with the patient’s radicular symptoms relieved. According to Wainner et al,10 the test is highly specific for a diagnosis of CR (0.86), with lower sensitivity (0.50). Neurological tests included deep tendon reflexes and myotomes. Bilateral upper extremity deep tendon reflexes (C5-7) were intact and equal except C6 (biceps) was diminished on the left. Bilateral cervical myotomes were tested in a seated position as described by Magee.2 C1-T1 myotomes were all negative bilaterally except C6 (elbow flexion/wrist extension) on the left. Palpation of the left upper and middle trapezius, scalenes, levator scapulae, and rhomboid major and minor revealed tenderness and increased muscle guarding. Evaluation Based on the physical examination findings, physical therapy services were appropriate to reduce pain and inflammation, improve posture, increase cervical ROM and strength, and improve body mechanics and work ergonomics. Diagnosis The patient’s medical diagnosis of cervical pain secondary to a herniated nucleus pulposus was confirmed by an MRI. The CPR was used to determine patient’s physical therapy diagnosis of CR. The patient had three of the four 8 items present: positive Spurling compression test, positive distraction test, and cervical rotation less than 60 degrees to the ipsilateral side. The CPR had a 94% specificity when three of the four items were present.12 The physical examination revealed the patient had signs and symptoms of CR with neurological deficits that were indicative of C6 nerve root compression. These physical findings were consistent with the MRI results. Physical impairments found during the examination included poor posture, limited ROM of the cervical spine, decreased strength of the elbow and wrist, positive Spurling compression test, positive distraction test, and increased tone and guarding of the cervical and scapular musculature. Prognosis According to the Guide to Physical Therapist Practice,20 80% of patients with CR should achieve expected outcomes within 8 to 24 visits over the course of 1 to 6 months. Cleland et al4 established a 4-variable model to identify patients with CR who were most likely to achieve optimal recovery with physical therapy interventions. These variables included age of <54 years, dominant arm not affected, symptoms not exacerbated with downward gaze, and multimodal treatment approach including manual therapy, cervical traction, and deep neck flexor strengthening. The patient fit 3 of the 4 variables based on history and physical examination; therefore, his prognosis was very good Health Science Science Nursing Share QuestionEmailCopy link Comments (0)