DEPARTMENT OF REHABILITATION MEDICINE

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

ENDORSEMENT NOTE
OCTOBER 31, 2019

Respectfully endorsing GONATISE, DAISY a 49 y/o female patient with (+) DM,
(-) HTN, (-) Cardiopulmonary condition and she was medically diagnosed with Lacunar
Infarction (L) Frontal & Temporal lobe prob secondary to atherothrombotic in
origin; HCVD FC II, Type II DM, ATP resolving; Cervical strain.

Present Problem:

1. Intermittent dull & aching pain (7/10) on the back of the head, neck & (B) Trapz
2. MS tightness on (B) Trapz
3. MS weakness on cervical motion towards AP
4. Difficulty on maintaining standing for prolong time.

Present PT Mx:

1. HMP & TENS on (B) Trapz x 20mins

2. Calliet neck exercise towards AP x 7sh x 10reps x 1set
3. GPS on (B) Trapz x 30sh x 3sets
4. Facial Massage x 5mins
5.Facial expression exercise infront of mirror x 10reps x 3sets
a. Smiling
b. Kissing
c. Pouting
d. Frowning
6. Rhythmic Stabilization x 10SH x 10 reps x 1 set

Home Instructions:

1. Self Stretching on (B) Trapz x 30sh x 3sets

2. Neck Retraction exercises x 10reps x 3sets

Patient was seen __ and treated every Tuesday/Friday on this month of

OCTOBER 2019. Pt was able to tolerate all PT mx given without any adverse effects. Pt
is cooperative towards all tx sessions. Please re-evaluate the Pt by Dr. JPC after __ tx
sessions. Please take good care of the patient.

PRECAUTION: BP Schedule of Patient: TF 9:00

Baseline: 110/80mmHg Schedule of Doctor: M-F 8:00 to 5:00
WARD: OPD

Noted by: Prepared By:

LESLEY ANNE T. CARANGUIAN, PTRP TABON, MARK DUANE D.

PT STAFF IN CHARGE AUPT INTERN ‘20
 DEPARTMENT OF REHABILITATION MEDICINE
ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

ENDORSEMENT NOTE
OCTOBER 31, 2019

Respectfully endorsing DELA ROSA, ROMULO a 53 y/o male patient with (-) DM, (-
) HTN, (-) Cardiopulmonary condition and she was medically diagnosed with Calficic
tendonitis (L) glenohumeral jt; De Quervains tenosynovitis (L); Frozen Sh, bilat;
Cystic duct leak resolved; Obstructive jaundice secondary to choledocholithiasis c
spontaneous stone passage; middle & inferior calyceal stone ® & microlithiasis (L)
non obstruction; valveolaar heart dse. (Mitral regurgitation) FC II.

Present Problem:

1. Intermittent dull & aching pain on (L) Sh (4/10) and wrist (2/10)
2. Ms tightness on (L) Sh towards flexion & ABD & wrist motion towards flexion,
extension, Ulnar deviation & Radial Deviation
3. Ms weakness on (L) Sh flexion, extension, Abduction, IR & ER, Wrist flexion,
extension, Ulnar Deviation & Radial Deviation (Graded 4/5)

Present PT Mx:

1. PWB on (L) hand x 20mins (dipping technique

2. HMP c TENS on (L) Sh x 20mins
3. US x 1.5 w/cm on (L) Sh & wrist x 5mins each
4. Grip strengthening on (L) hand using black hand grip x 7SH x 10reps x 1set
5. MFR on paracervical area x 5mins
6. PJM on (L) Sh using spencer technique towards all motion x 30 osc x 10reps x
1set
7. Cybex ex on (B) UE towards triceps pull & chest press using 4 plates x 10reps x
3sets
8. Entrée pulley on (L) Sh with 5 plates on level 17 as to elbow flexion and level 13
as to shoulder flexion & abduction x 10reps x 2sets
9. Treadmill exercise:
A. Warm up x 5mph x 2mins
B. Program proper x 7mph x 6mins
C. Cool down x 2mph x 2mins

Home Instructions:

1. Wand exercise towards flexion, extension, abduction and adduction x 7SH x

10reps x 3sets

Patient was seen __ and treated every Tuesday/Friday on this month of OCTOBER
2019. Pt was able to tolerate all PT mx given without any adverse effects. Pt is cooperative
towards all tx sessions. Please re-evaluate the Pt by Dr. SOR/JPC after __ tx sessions.
Please take good care of the patient.

PRECAUTION: Burn Schedule of Patient: WF 8:30

Baseline: 120/80mmHg Schedule of Doctor: M-F 8:00 to 5:00
WARD: OPD

Noted by: Prepared By:

LESLEY ANNE T. CARANGUIAN, PTRP TABON,MARK DUANE D.

PT STAFF IN CHARGE AUPT INTERN ‘20