Manila Adventist College

College of Allied Health

Department of Physical Therapy

PHYSICAL THERAPY INITIAL EVALUATION

General Information

Name: J.S.

Age: 43 y/o

Sex: M

Address: Antipolo City

Civil status: Married

Occupation: Gas service attendant

Handedness: R

Weight: 127 pounds

Height: 5’6

BMI: 20.5 (N)

Referring Unit: Antipolo Medical Center – Pulmonary Dept

Referring MD: Dr P. J

Rehab MD: Dr H. M

Date of Consultation: Oct 29, 2025

Date of referral: Oct 29, 2025

Date of IE: Nov 1, 2025

Type of pt: out-pt
Informant/reliability: pt/good

Dx: Mild Panlobular Emphysema (GOLD Classification)

c/c: pt c/o SOB (RPE:5/10) while walking approximately for 15 mins, stair negotiation, and when doing
household chores such as when cleaning the house. Pt also c/o an intermittent non-productive cough and
fatigability during work (RPE: 4/10) Pt also c/o difficulty in jogging because of SOB (RPE: 7/10)

pt’s goals: pt wants to reach his maximum lung function so that his SOB will decrease while walking for
approximately 15 mins, while negotiating stairs, and while doing household chores. Pt also wants to
manage his intermittent non-productive cough and fatiguability and wants to increase his jogging time.

HPI

8 mos PTIE: Pt c/o SOB while he was jogging for approximately 15 mins (RPE: 5/10). Pt mentioned that
he was bothered by this because he usually just experiences a scale of (RPE: 3/10). Pt just went home to
rest (RPE: 0/10). pt also c/o of intermittent non-productive cough.

4 mos PTIE: Pt mentioned that he started feeling SOB while negotiating stairs (RPE: 3/10). pt ignored his
sx. Pt reported he noticed some weight loss of 2.5kg.

2 mos PTIE: Pt c/o SOB while walking on his way to work for approximately 15 mins (RPE: 5/10). Pt
also mentioned his jogging time decreased because of SOB (RPE: 7/10). pt relieves sx by slowing down
(RPE: 3/10).

3 days PTIE: Pt experiences fatigue during work (RPE: 4/10) and SOB when he cleans the house (RPE:
4/10). Pt was worried about his well-being and started to consult a doctor. Pt was asked to undergo some
medical procedures (see ancillary procedures). Pt was dx c mild panlobular emphysema and was referred
for rehabilitation.

At present: pt c/o SOB (RPE:5/10) while walking approximately for 15 mins, stair negotiation, and when
doing household chores such as when cleaning the house. Pt also c/o an intermittent non-productive
cough and fatigability during work (RPE: 4/10) Pt also c/o difficulty in jogging because of SOB (RPE:
7/10)
ANCILLARY PROCEDURES

TEST DATE FINDINGS

CXR
Oct 29, 2025 (+) (B) hyperluscent on lower
AP and LATERAL VIEW lobes of lung
(-) increase retrosternal space
(-) widened xiphisternum
(-) scoliosis
(-) cardiomegaly
(-) pulmofibrosis

CT SCAN
Oct 29, 2025 (+) panlobular emphysematous
Axial Lung Window View pattern on (B) lower lobes of
lung
(-) hyperinflation on (B) lungs
(-) destruction of lung
parenchyma on (B) lungs

↑ RV (2L)
PFT ↑ FRC (3.5L)
Oct 29, 2025
↑ TLC (7.5L)
↓ FVC (81%)
↓ FEV1 (83%)
↓ FEV1/FVC (80%)

LABORATORY TESTS
Date Taken: Oct 29, 2025

TEST Normal Values Findings

AAT 78-200 mg/dL 65 mg/dL

Liver Function

AST (hepatocyte integrity) 0.08 to 0.83 ukat/L 0.09 ukat/L

Serum Bilirubin (biliary 1.70 to 8.55μmolL 4.52 μmolL
excretory function)
Serum Albumin (hepatocyte 3.4 to 5.4 g/dL 4.3 g/dL
synthetic function)
Serum Ammonia (hepatocyte 10 to 80 µg /d 50 µg /d
metabolism)

HEMATOLOGY
Component Results Unit Normal Range

5.12 x106/mm3 4.60-6.20

RBC

500.00 x106/mm3 140.00-440.00

Platelet Count

12.00 x106/mm3 4.50-10.00

WBC

75.00 % 56.00-66.00
Neutrophil

45.00 % 22.00-40.00
Lymphocyte

9.00 % 4.00-8.00
Monocyte

5.00 % 1.00-4.00
Eosinophil

6.00 % 1.00-4.00
Basophil

DRUG HISTORY

Medication Date taken Dosage/Frequency Indication Side effect

Salmeterol 50 mcg bid 12 Long-term Tachycardia

hours apart maintenance for Palpitations
inhaled bronchodilation GI distress
and bronchospasm Nervousness
Tremor
Headache
Dizziness

Zemaira 60 mg/kg protein alpha 1- runny or stuffy

 intravenously once proteinase nose, sneezing,
a week cough, sore throat

PMHx

(-) Htn
(-) trauma
(-) hospitalization
(-) cardiovascular conditions
(-) other pulmonary conditions

FMHx

Conditions Paternal Maternal

Alpha-1 anti-trypsin deficiency (+) (-)

Pneumonia (-) (-)

Chronic Bronchitis (-) (-)

Asthma (-) (+)

Cardiovascular disease (-) (-)

CA (-) (-)

DM (-) (-)

PSEHx

● Type B Personality
● Sedentary lifestyle
● Smoker (1/2pack per day x 3 years) = 0.5 units
● pt is exposed to gas irritants
● Occasional drinker (approximately 2 bottles every 9 months)
● Diet: Vegetables, Meat, Fruits
● Hobby: Jogging

Home Situation
● Pt lives c his family
● Pt lives in a bungalow house ~ 50 square meters
● Main door to bedroom ~ 25 steps
 ● Bedroom to kitchen ~ 15 steps
● Bedroom to comfort room ~ 10 steps

Work situation
● Pt works from 8am to 5pm (Monday to Friday)
● Working as a gas service attendant for 10 years
● Break time ~ 12pm-1pm
● Distance from jeepney stop to workplace ~ 300 meters
● Flight of stairs in their office ~ 15 steps

Before During After

BP 120/80 130/80 120/80

PR 60 bpm 70 bpm 63 bpm

RR 17 bpm 20 bpm 20 bpm

temperature 36.3 36.5 36.4

Findings: Pt’s systolic pressure increased during tx. PR, RR, and temperature also increased during tx.
Significance: Pt’s VS increased due to decreased endurance. PT mx should include increasing endurance
capacity. This should also be used for precautionary measures.

Pulse oximetry

Before During After

SPO2 98% 97% 97%

Findings: Pt’s oxygen saturation is not WNL during, and p treatment

Significance: Pt’s oxygen saturation decreased due to mild paanlobular emphysema. PT Mx should
include increasing pt’s endurance and

OI:
 Pt is ambulatory
● Ectomorph
● Pt in slight distress every time he coughs
● Experiences difficulty when exhaling
● (+) (see postural analysis)
● (+) (see gait deviation)
● (+) nicotine stains on ® fingers
● (+) chest breather
● (+) tripod position
● (-) pursed lip breather
● (-) hypertrophy of accessory muscles in respiration
● (-) dyspnea of phonation
● (-) nasal flaring
● (-) central cyanosis
● (-) jugular vein distension
● (-) (B) UE and LE swelling
● (-) (B) UE and LE digital clubbing
● (-) (B) UE and LE edema
● (-) (B) UE and LE incisions
● (-) (B) UE and LE scars
● (-) other chest deformities

Palpation:
● Normothermic on (B) UE and LE
● Normotonic on (B) UE and LE
● LOM in (B) shoulder horizontal abduction, cervical extension, and thoracolumbar extension
● mm weakness in (B) Shoulder Horizontal abduction, cervical extensors, (B) sternocleidomastoid,
(B) scapular adductors trunk extensors, quiet inspiration, forced expiration
● (+) inward motion of costal margins during inspiration
● (-) flat diaphragm
● (-) vocal fremitus on apical, anterior, lateral, and posterior areas of the chest.
PULMONARY Ax

Auscultation

Lung Lobe Segment Findings

R and L lower lobe anterior apical segment Diminished breath sounds
R and L lower lobe anterior segment Diminished breath sounds
R and L lower lobe posterior apical segment Diminished breath sounds
R and L lower lobe posterior segment Diminished breath sounds
Rest of lung segments Vesicular

Significance: Pt has diminished breath sounds on B lower lobe segments of his lungs due to mild
emphysema. Pt’s condition should be managed to prevent disease progression.

Voice sound
Findings
Bronchophony Muffled 99
Egophony E sound
Whispered Pectoriloquy Absent sound

Significance: This is to rule out other pulmonary conditions.

Tactile Fremitus

Findings
Tactile Fremitus Decreased vibration on lower lobe segments of
(B) lungs
Significance: Pt’s has decreased vibration on lower lobe segments of (B) lungs due to hyperinflation. Pt
should be taught how to do proper breathing techniques.

Percussion

Lung Lobe Segment Findings

R and L lower lobe anterior apical segment Hyper resonant
R and L lower lobe anterior segment Hyper resonant
R and L lower lobe posterior apical segment Hyper resonant
R and L lower lobe posterior segment Hyper resonant
Rest of lung segments Resonant

Significance: Pt has hyper resonant lower lobe segment of (B) lungs due to mild emphysema. Pt mx
should include proper breathing exercises

COSTOVERTEBRAL EXPANSION

LANDMARKS Exhalation Inhalation Difference

Sternal angle 32 in 35 in 3 in
4th ICS 31in 35 in 4 in
Nipple line 32 in 36 in 4 in
T10 30 in 33 in 3 in

Findings: Pt had a shorter length when exhaling than during inhalation.

Significance: Pt had a difficult time exhaling because of increased air trapped inside the lungs. Pt should
be taught proper breathing techniques.

ROM: All joints of the (B) UE, LE, spine and thorax are actively and passively done WNL c N end feel
except for the following:

MOTION AROM DIFFEREN PROM DIFFEREN N VALUE END FEEL

CE CE

(B) 0-20 10 N N 0-30 firm

Shoulder
Horizontal
abduction

Cervical 0-30 15 N N 0-45 firm

extension

Thoracolum 0-70 10 N N 0-80 firm

bar
extensors

Findings: LOM in (B) shoulder horizontal abduction, cervical extension, and thoracolumbar extension

Significance: LOM is due to tightness or use of accessory mm in respiration. PT Mx should include ROM
exercises and stretching exercises.

MMT: All mm groups of (B) UE, LE as well as spine and thorax were assessed and were graded 5/5
except for the following

Mm group Grade

(B) Shoulder Horizontal abduction 4

Cervical flexors 4

(B) Combined flexion to isolate a single 4

sternocleidomastoid

(B) Scapular adductors 4

Trunk extensors 4

Quiet Inspiration 4

Forced Expiration functional

Findings: mm weakness in (B) Shoulder Horizontal abduction, cervical extensors, (B)

sternocleidomastoid, (B) scapular adductors trunk extensors, quiet inspiration, forced expiration

Significance: mm weakness is due to postural compensation. PT mx should include strengthening

exercises.

POSTURAL Ax: Pt was assessed in a standing position outside // bars

A/P View Landmark Lateral View

In midline Head/neck Forward head, minimal cervical

 flexion

Leveled Shoulder Protracted

Protracted Scapula Neutral

Midline Thoracic Decrease lumbar lordosis

Midline Lumbar Increase in lumbar kyphosis

Neutral Elbow Neutral

neutral Wrist/Hand neutral

Leveled Pelvis Posteriorly tilted

aligned Hip Minimal hip flexion

Leveled patella Knee Leveled fibula

Leveled malleoli Ankle Neutral

Findings: pt is in tripod position

Significance: postural deviation is due to compensation because of SOB. PT mx should include postural
correction to facilitate proper breathing
GAIT ANALYSIS: Pt was assessed walking on a flat surface outside // bars s assistive device. Pt’s gait
pattern are WNL except for the ff:

REFERENCE LIMB ARM SWING

Left Decrease in arm swing
Right Decrease in arm swing

PARAMETERS N VALUES RESULTS

Cadence 90-120 steps per minute 117 steps/min

Stride Length 57 in 51 in

Step Length 28 in 25 in

Findings: Pt’s gait pattern is WNL except for limited hip flexion during swing phase, arm swing, and
spatial parameters

Significance: pt’s presents limited hip flexion, arm swing, and spatial parameters due to SOB and postural
deviations. PT Mx should include endurance exercise and gait exercise

BBS: Pt’s risk of falls was assessed.

ACTIVITY SCORE

SITTING TO STANDING 4

STANDING UNSUPPORTED 4

SITTING C BACK UNSUPPORTED BUT FEET 4

SUPPORTED ON FLOOR OR ON A STOOL

STANDING TO SIT 4

TRANSFERS 4

STANDING UNSUPPORTED C EYES CLOSED 4

STANDING UNSUPPORTED C FEET 4

TOGETHER

REACHING FORWARD C OUTSTRETCHED 4

ARM WHILE STANDING

PICK UP OBJECT FROM FLOOR FROM A 3

STANDING POSITION

TURNING TO LOOK BEHIND OVER YOUR 4

LEFT AND RIGHT SHOULDERS WHILE
STANDING

TURN 360 4

PLACE ALTERNATE FOOT ON STEP OR 4

FOOT WHILE STANDING UNSUPPORTED
STANDING UNSUPPORTED ONE FOOT IN 4
FRONT

STANDING ON ONE LEG 4

Findings: Low risk of fall

Significance: Low risk of falls is due to oxygen levels. PT mx should include endurance exercise

6-MWT: Pt walked on a flat surface s assistive device

Pre-Test End of Test

BP 120/80 BP 130/80

HR 17 bpm HR 22 bpm

SPO2 98% SPO2 97%

Dyspnea (Borg) 1 Dyspnea (Borg) 5

Fatigue (Borg) 2 Fatigue (Borg) 4

Stopped or paused before 6 minutes completed? Patient paused 1

time
 Did the pt experience other sx at the end of the No
test

Total distance walked in 6 minutes 330 meters

Findings: Pt was able to walk for 330 meters c 1 pause in 6 minutes. Pt felt SOB (RPE: 5) at the end of
the test.

Significance: Pt’s SOB is due to mild emphysema. PT mx should include increasing pt’s cardiopulmonary
endurance to help him manage his dyspnea

MMRC DYSPNEA SCALE

Grade 1 breathless only on strenuous

exertion

Grade 2 breathless when walking up a

slight hill

Grade 3 breathless when walking on flat

ground

Grade 4 breathless on walking

100metres

Grade 5 breathless on dressing or

undressing

 
Findings: Grade 1

Significance: Pt’s experienced decreased endurance manifested by SOB. PT Mx should include

improvement of functional capacity so that pt can perform prolonged activities.

BODE INDEX

VARIABLE POINTS ON BODE INDEX

0 1 2 3

FEV1 >65% 50-64 36-49 <35

(%predicted)

6MWT (meters) >350 250-349 150-249 <149

MMRC dyspnea 0-1 2 3 4-5

scale

Body Mass Index >21 <21

Findings: 2 points

Significance: Pt has a high chance of survival since. Pt is not yet underweight, has an FEV1 of more than
65%, and was able to walk more than 350 meters during 6MWT due to mild emphysema. Disease
progression should be managed so that patient can improve and then maintain his current condition.
Functional Ax

COPD ASSESSMENT TEST (CAT)

Findings: Total Score: 14

Significance: In some aspects of pt’s life he has a poor view on his quality of life. However, PT mx
should include pt education about smoking cessation and decrease progression of sx and functional
activities.
NEUROLOGICAL ASSESSMENT

SENSORY AX

SUPERFICIAL STD USED TRIALS PERCENTAGE

SENSATION

Pain Large headed safety pin 3/3 100%

trials

Temperature Two test tubes c stopper (warm water and 3/3 100%
crushed ice) trials

Touch Cotton swab 3/3 100%

trials

Pressure Double-tip cotton swab 3/3 100%

trials

DEEP SENSATION

Kinesthesia Awareness none 3/3 100%

trials

Proprioceptive Awareness none 3/3 100%

trials
 Vibration Tuning fork 3/3 100%
trials

Findings: Pt has 100% intact superficial and deep sensation on (B) UE and LE

Significance: to rule out possible neurological affectations

DTR

Findings: (B) UE and LE are grossly assessed and were found to be N

Significance: to rule out possible neurological affectations

PT IMPRESSION:
Pt is MDDx c mild panlobular emphysema further defined by impairments such as SOB (RPE:5/10) while
walking approximately for 15 mins, stair negotiation, and when doing household chores such as when
cleaning the house, intermittent non-productive cough and fatigability during work (RPE: 4/10). LOM
and mm weakness was also assessed in our pt. This makes it difficult for him to do his leisure activities
such as jogging and his role as a gas serving attendant. Pt’s prognosis is fair and PT mx should include
preventing further progression by increasing and improving cardiopulmonary endurance and capacity.

REHAB POTENTIAL: Pt has a fair prognosis due to the following reasons

Favorable Non-favorable

● Pt’s SOB only presents during strenuous

activity ● Pt’s condition is irreversible
● Pt is not underweight ● Positive in alpha1 anti-trypsin deficiency
● Low risk of fall ● Pt is a smoker
● Pt has good diet ● Pt is exposed to gas irritants
● BODE Index ● Pt’s age
● Pt received early PT rehabilitation

Problem List
1. SOB (RPE:5/10) while walking approximately for 15 mins, stair negotiation, and when doing
household chores such as when cleaning the house
2. Decrease endurance during 6MWT (RPE: 5/10)
3. fatigability during work (RPE: 4/10).
4. Intermittent non-productive cough (CAT score: 5)
5. LOM in (B) shoulder horizontal abduction, cervical extension, and thoracolumbar extension
6. mm weakness in (B) Shoulder Horizontal abduction, cervical extensors, (B) sternocleidomastoid,
(B) scapular adductors trunk extensors, quiet inspiration, forced expiration
7. Postural deviation
8. Gait deviation
9. Quality of life (CAT Score: 14)
10. BBS Score: 55
11. decreased breath sound of (B) lungs.
12. Oxygen saturation is not WNL during and p tx
13. BODE INDEX: 80% survival rate next 4 years

LTG: In 5 mos of PT sessions,pt will reach his maximum functional capacity that will manifest by
increase in endurance and manageable symptoms.
STG: In 1 mos of PT sessions (3 x a week). Pt will demonstrate

1. Reports decrease in SOB (RPE: 5  3) while walking approximately for 15 mins, stair
negotiation, and when doing household chores such as when cleaning the house
2. Increase endurance during 6MWT (RPE 5  3)
3. Decrease fatiguability during work (RPE 4  2)
4. Decrease in intermittent productive cough (CAT score: 4  2)
5. Achieved N ROM
6. Achieved N MMT
7. Pt can present proper posture
8. Improvement in gait patterns
9. Quality of life increase in (CAT score: 14  10)
10. Achieved N BBS score

PT Mx
1. Breathing exercises
a. Pursed lip breathing x 5 cycles
b. DDBE in sitting x 5 cycles

2. Aerobic exercise
a. Treadmill walking x progression as tolerated as possible

3. GPS 15 sh x 10 reps
a. (B) scalene
b. (B) SCM
c. (B) Pectoralis Major

4. Strengthening exercise
a. Diaphragm x 2 plates x 10 reps x 2 sets
b. Rhomboids x yellow TheraBand x 10 reps x 2 sets
c. Deep cervical extensors x chin tuck x 10 reps x 2 sets
d. Thoracolumbar extensors x prone position on vestib ball x 10 sh x 5 reps

HEP

1. Proper body mechanics and postural stabilization

 2. Moderate intensity aerobic exercise for 20-30 mins
3. Breathing exercises
a. Pursed lip breathing technique x 10 cycles x 3 times a day

Pt education

1. Smoking cessation
2. Explaining in layman’s term the anatomy and physiology of pt’s disease
3. Provide information about patient’s specific disease and mx
4. Remind the patient to always do proper airway clearance techniques
5. Nutritional considerations
6. Effects and Adverse effects of medications
7. Use of mask when working to avoid environmental irritants

PT-In-Charge: