
 Name: M sharjeel
 Roll #: 11956
 Dpt 8th C
 Supervised clinical practice

Subjective Assessment
Name:
M Amir
Age:
36 years
Gender:
male
IP/OP
OP
Marital status:
Married
Occupation:
Shopkeeper
Address:
Madina town, Fsd

Chief complaint: Patient came to OPD with low
back pain that was Radiating to his left leg due to
which he was facing difficulty in walking.
Patient need: Pain relief and pain free
movement
Date of admission: 5-5-2023

 History of presenting complaint:
 The patient has low back pain from last 7 days that was
worsening with passage of time. The pain started when
patient was uplifting heavy weight material in shop
 Past medical history:
 The patient has history of low back pain 6 months ago.
But on that time orthopedic surgeon gave him some
medicine(tab synflex 550 mg, thiolax 04 mg twice a day)
for 10 days. After using the prescribed medicine the
patient got better but he feels low back pain sometimes
whenever he had to lift weight or have to do forward
bending.

 Family history:
 The patient is non smoker and no other medical
problems.
 Living environment:
 Clean and hygienic environment
 Family History:
 Mother is Diabetic+hypertension+ osteoarthritis.
 But there is no effect of family history on patient’s
current scenario.

Side:
Left leg
Site
Lumbar regio
Onset:
1 week ago
Duration
Persistent
Type :
Stabbing
Severity
Aggravating
factors
Standing,
Relieving
walking and
factors
stairs climbinv
7/10 on pain
scale
Pain killer

Swelling
Erythema
Inspection
There was
Joint
mild swelling deformity
at left feet
Muscle
wasting
No
No
No
Palpation
Temperatur 98F
e
Tenderness There was
Inflam No
mild
mation
tenderness of
left leg
hamstrings

Edema
No
Contr No
acture
Crepit Patient feels
ations
Crepitations
sound in his knee
but there is no
correlation of it
with his problem.
On examination

Level of
conscious
ness
Sensation
Orientation
Person
Touch
3 into 3
Temperature
Memory
 Short term : Good
 Long term : Good
Superficial
 Touch
2
 Pain
2
 Temperature 2
Deep
 Deep pressure
 Kinesthetic
 Proprioception
Communication
verbal: Good
Non-verbal: Good
Combined
4  2point
4
discrimination
4
normal
 Stereognosis
normal
 Graphesthesia
normal
 Barognosis
normal
Reflexes
Deep tendon reflexes(0,1,2,3,4)
 Biceps tendon(C5,6)
 Brachioradialis tendon(C5,6)
 Triceps tendon(C6-8)
 Patellar tendon(L2-4)
 Planter flexors(S1,2)
Primitive reflexes
 Plantar reflex
 Abdominal reflex

2
2
2
2
2
2
2
Grades:
0 - No response
1- diminished
2- Normal
3- Slightly hyperactive
4- Clonus

Muscle tone (Ashworth scale)
(0, 1, 1+, 2, 3, 4)
U/E
L/E
Right
Normal
Normal
Trunk
Not tested
Left
Normal
Left leg muscle
was Hypertonic
+1
Not tested

ROM
U/E
L/E
Right
Normal
Normal
Trunk
N.T
Left
Normal
Normal except
hip felxion SLR
was 40 degree
only after the
patient feel
severe pain.
N.T

MMT
Right
Left
U/E
5/5
5/5
L/E
5/5
Trunk
5/5
3/5 Due to pain
patient was
unable to use
his Muscular
strength
actively
5/5
Co-Ordination tests













Non equilibrium tests
Finger to nose
4
Finger to finger
4
Heel on skin
4
Rebound phenomenon 4
Drawing circle
4
Equilibrium tests
Sitting, weight shifting in all direction 4
Sitting, multidirectional function reach 4
Standing, standing feet together
4
Standing on one foot
4
Walking, forward, backward, sideways 4

 Investigation:
 Blood test: Normal
 X ray: Lumbar spine straightening with reduced
intervertebral space.
 MRI: Result shows severe muscular spasticity and
lumbar curve straightening. There was moderate
disc buldging at L4-L5 and S1
Problem lists









Activity limitation:
Difficulty walking and stair climbing
Difficulty in sleeping
Inability to life heavyweight
Participation restriction
ADL’s restriction like work at shop
Physiotherapy diagnosis:
Lumbar radiculopathy( sciatica)
Management

 Short term goals
 Pain relief
 Restore his ADL
 To Restore his normal gait patter .
 Long term goals
 Strengthening the paraspinal muscles.
 Regain functional activities

 Electrotherapy:
 Use of ultrasound 1MHz for 6 months( to control
inflammation at L4-L5 & S1 disc.
 Moist hot pack to relax paraspinal muscles
 TENS to control the pain.
 Manual therapy:
 Stretching exercise Quards+hams+calfs
 Mckenzie technique exercise.










Exercise Therapy:
Strengthening exercise
Bridging exercise
swinmming
Home Plan:
Avoid forward Bending
Use semihard or ortho mattress for sleeping.
Place one pillow while lying in right side line.
Do bridging exercise, MacKenzie techniques.
