The following is the information you noted while completing the Systems Review and Teits and Measures portions of the initial evaluation for your patien

The following is the information you noted while completing the Systems Review and Teits and Measures portions of the initial evaluation for your patient. In the space provided, mark the statement with either SR for Systems Review or TM For Teits and Measures to indicate where the information best fits. Then use the information you marked as

5R

to cotnplete the Syitems Review form provided. Finally, fill in the information you marked as TM under the correct Tests and Measures heading in a logical order using the headings provided. Patient: Donnie C Setting: Outpatient Orthopedic Clinic 1. He

6 

2

 2 

∗

 ;

Wt 1873 2.

10.5 cm

length, well-healed scar over ipinous proceises 1. S. I: normalued movement of tissue around scar 3. trunk strength: upper abdomen: 2-15; lower abdoment trace/5; back ext: 1/5 4. AROM: prone hip internal rotation: (A) LE. 21* (1) 1F. I4 5 Sencutiont light touch intact bilat UE & L.E in all dermatomal patterns to tho point discrimination except moderatedy in generalized manner on plantat surface of feet 2 to to underlying peripheral neuropathy. 6. Nett & Oriented to person, place, time, & situation. Unimpaired. 7 Modified Schocber’c flex, 2cm ce do T pain, ext. 0 cm c clo t pain 8. Coordination intact 2 heel-shin, reciprocal toe tapping in sitting 9. Supine

↔

situing at edee of mat:indep 10 Palpation: (+) tendemen to palpation over spinous processes 13.15. T muscle guarding throughout bilat paraspinal musdes L1-1.5 11. Communicates vertully throughout sesson in English 5 ditticulty 12. Normal afiect, Good eye contact 2 PT throughout session. 11 . lumbar iphere 11. Communicates verbally throughout session in English 5 difficulty. 12. Normal affect. Good eye contact 2 PT throughout session. 13. Flexibility: prone knec flex/quad length:(B) I.E

90 

∘

 c

c/o pain in lumbar spine, () L.E

86 

∘

 C

c/o pain in lumbar spine 14. Gross strength (8) LE:

4/5

8 gluleus maximus 3-15, hip internal rotation 3+ 35 , hip external rotation

3/5

, ankle dorsiffexion

3+15

15. Cardiopulmonary: BR. 142/72: HR.81 bpm: RR 18 bpm;

SpO 

2

​

 .98%

on room air. No edema noted bilat UE or LE 16. Needs written. HEP program s pictures for pt to reference at home. 17. Wears bifocals at all times; unable to read or drive 5 them. 18. Flexibility: hamstring 90/90 test – 39 (R) LE:-35* (C)LE: 19. Posture in standing: 4 lower greater than upper lumbarlordosis, post pelvic tilt, forward head, thoracic spine kyphosis, protracted shoulders bilat: liac crest height equal. 20. Gross strength (L) LE:1-15 for hip tlex, quadriceps hamirings,3/15 hip abd, 3/5 hip internal rotation, hip external rotation, ankle plantar flexion:3/2 Sgluteus maximus, ankle dorsiflexion 21. Prefers to learn by visually seeding demofirst &then attempting task Notes,

1 m

a woul guy That’s how llearn things: 22. sitistanding indep 23. Follows 1 & 2-step commands 1009 s difficulty c good amention to take Unimpaired 24. Pt reports generalized thearing

x

to years 2 “to ‘old work accident t requiring “people to talk foud so I can hear them clearly.” 25. hip on knee flex during swing phase (C) greater than (B) 1. contact, (L) foot alap it to I cecentric ant tibialis strefighth that os more pronounced ef fatigue. 26. 27. Striest (-) bilat Le 28. Tone normalized throughout hilat UE & LE unitipaired 29. Skint integrity & color normal. 30. PART III. The following is the information yout noted while completing the Systems Review and Tests and Measures portions of the initial evaluation for your patient. In the space prosided, mark the statement with either SR for Systems Review or TM For Tests and Measures to indicate where the information best fits. Then use the information you marked as SR to complete the Systems Review form provided. Finally, fill in the information you marked as TM under the correct Tests and Measures heading in a logical order using the headings provided. Patient: Donnie C Setting: Outpatient Orthopedic Clinic 1.

Ht⋅6 

∘

 ;Wt:187 s

2.

10.5 cm

length, well healed scar over spinous processes 1.2-51; normalizd movement of tissue around scar trunkstrength: upper abdomen: 2-15, lower abdomen: trace/5; back ext i is 3. 4. AROM: prone hip internal rotation: (A) IE:

21 

4

 

(i) 1E:

14 

∗

 

5. Sensation: light touch intact bilat UE

Ξ

L.E in all dermatomal patterns to two point discrimination exiept moderately & in generalized manner on plantar surface of feet

2 

2

 

to underlying peripheral neuropathy! 6. Alert & Oriented to person, place, time, & nituation, Unimpaired. 7. Modified Schocber’s flex

2 cm

₹ clo T pain; ext, 0 crr 2 clo f pain 8. Coordination intact c heel-shin, reciprocal toe tapping in sitting 9. Supine

⟶→

sitting at edge of mat: indep 10. Palpation:

(t)

tenderness to palpation over spinous processes

L3−15,1

muscle guarding throughout bilat paraspinal muscles 1.1-15 11. Communicates verbally throughout session in English 3 difficulty. 12. Normal affect. Good cye contact 2 PT throughout session. 13. lumbar spine 14. Gross strength (8) LE:

4/5×

gluteus maximus 3-15, hip internal rotation

3+15

, hip external rotation

3/5

, ankle dorsiflexion

3+15

15. Cardiopulmonary: BP. 142/72; HR: 81 bpm: RR: 18 bpm: SpO,

98%

on room air. No edema noted bilat UE or LE 16. Needs written HEP program c pictures for pt to reference at home. 17. Wears bifocals at all times; unable to read or drive s them. 18. Flexibility: hamstring

90/90

test

−39 

∗

 

(B) L.E:

−35 

∘

 

(C) LE 19. Posture in standing:

↓

lower greater than upper lumbar lordosis, post pelvic tilt, forward head, 20. Gross strength (C) LE: 4-15 for hip flex, quadriceps, hamstrings:3+/5 hip abd, 3/5 hip internal rotation, hip external rotation, ankle plantar flexion: 3-15 gluteus maximus, ankle dorsiflexion 21. Prefers to learn by visually seeing demo first & then attempting task. Notes, “I’m a visual guy. That’s how 1 learn things,” 22. site standing: indep 23. Follows 1 & 2 -step commands

1005ξ

difficulty

e 

good attention to task. Unimpaired 

 

24. Pt reports generalized

↓

hearing x 10 years

2 

∗

 

to “old work accident,” requiring “people to talk loud so I can hear them clearly.” 25. Ambr amb into & throughout OP dink

100 

−

 ×1

on smooth. level surface

Z

turns indep 5 device

c

gait deviations of

↓

cadence,

↓

step length bilat,

↓

lat weight shift bilat during stance phase,

↓

bilat hip & knee flex during swing phase (C) greater than (A) 1.E, moderatdy

↓

(1) heel strike at initial contact, (C) foot slap

2 

7

 

to

+

eccentric ant. tibialiestrength that is more pronounced Z fatigue. 26. Single les sance test average of 3 trials: (8) t.E 19 eecit) I.

5sec

27. SLRtent: (-) bitat L.E 28. Tone: normalized throughout bilat UE šLE urimpaired. 29. Skin- integrity & color normal. 30.