Cervical Spine Evaluation
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Last name |
Jacob |
Name |
Cyril |
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Injury date |
0/0/0 |
Physician |
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Folder ID |
1 |
Evaluation date |
10/10/2002 |
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Diagnosis : |
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Subjective assessment
Functional status
Activities of daily living: No rotation of the cervical spine. Mobility greatly reduced
Restricted activities: Bad sleeping, unable to work
Past health status: Had a surgery in the past in the C5-C6 aera
Health status: Allergia against aspirin.
X Rays/other tests: positive X-Rays at C6 region. Teared muscle
Dominant side: Left
Pain description
Legend used in pain and paraesthesia diagram.
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: Paraesthesia |
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: Pain. |
Objective assessment
Local oedema
Type : Pitting Soft
Posture:
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Head |
Not evaluated |
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Shoulder |
Not evaluated |
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Cervical lordosis |
Normal |
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Dorsal kyphosis |
Normal |
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Vertebral alignment |
Well aligned |
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Legend used in mobility diagram.
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: Side pain |
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: Movement deviation |
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: Central pain. |
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: Arc of pain |
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: Central pain, radiating unilaterally |
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: Central pain, radiating bilaterally |
Test
Dizziness Test
Step #1:
Passive Neck rotation :Positive
Note :
Step #2:
Passive trunk rotation :Positive
Note :
Conclusion
Problem with vertebral arteries [X]
Problem with semicircular canals in innerear [ ]
No conclusion [X]
Treatment plan
List of treatments
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Problem |
Description |
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Bands |
McConnell |
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Bike |
Resistance #4, X5 |
List of exercises
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Exercise |
Description |
| Cervical spine ROM retraction scapular |
With cautions |
Treatment plan was explained to patient and he(she) accepts it :Yes
Number of treatment planned :9
The patient will be treated initially 3 times per week
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| Date | Physical therapist |
