LORMA COLLEGES

PT INITIAL EVALUATION

GENERAL INFORMATION

Patient’s name : E.F

Age : 4 y/o
Sex : Male
Address : Canaoay, City of San Fernando , LU
Civil status : Single
Citizenship : Filipino
Handedness : (R)
Occupation : none
Religion : Roman Catholic
Referring MD : Dr. D
Referring Unit : OPD
Attending Dr. : Dr. N.R
Date of Consultation : N/A
Date of Referral : N/A
Date of Initial Evaluation : 2/11/17
Diagnosis : Cerebral Palsy

S:

c/c: “ nahihirapan siyang tumayo, hindi niya mabalance yung katawan niya kapag naglalakad,
nahihirapan din siyang mag salita,at kumain, tapos bigla bigla nalang may involuntary movement sa
katawan niya

PT Translate: Pt’s mother c/o her daughter’s difficulty in standing, loss of balance while walking
difficulty in ADL’s such as speaking and eating. Pt’s mother stated that her daughter has
involuntary movement.”
HPI:
Informant: Pt’s mother
 Present condition started approximately 3 yrs. PTIE when pt.’s mother taking meds for her
maintenance for her HTN. Pt. had fever at the 3rd mon of gestation but no meds to take. The
baby was normally delivered by his mother at ITRMC, Dr. noticed of bluish color of the baby, c
umbilical cord wrapped on the neck and R UE and LE. At 3 mons. old of the pt. when pt’s mother
noticed her daughter had an absence of rolling in bed and weakness of muscles. They decided
to go at LMC to seek medical attention to Dr. E and underwent procedures (unrecalled results
and types of ancillary procedure). Pt. diagnosed of Cerebral palsy.

Pt. was referred immediately to PT Rehab at LMC for PT mx (unrecalled PT Mx and

parameters). P 1 yrs PT tx, they discontinued d/t financial problems.
3 mo PTIE when pt got seizure attack. Pt. was confine at ITRMC for 3 days. Rx meds and
done ancillary procedures but unrecalled.

At present, pt. had mx. Difficulty in ADL’s such as ambulation, dressing, grooming,
feeding, writing, communicating and loss of balance and has involuntary movement.

Maternal Hx:
Pt’s mother is G3P3, preganant to the pt. @ 36y/o. Took medication of HTN maintenace c
compete vacination and has a sedentary lifestyle during pregnancy.
Birth Hx:
 AOG: 36 wks
 Normal delivery
 APGAR Score: (unrecalled)
 Appearance= Bluish
 Pulse= N/A
 Grimace= N/A
 Activity= N/A
 Respiration= N/A
 Head circumference N/A
 Birth length: N/A
 Birth wt: N/A

Nutritional Hx:
 Pt was breastfed: N/A
 (+) Bottlefeeding
 Semi solid: N/A
 Pt has a good appetite
PMHx:
Pt. has history of hospitalization (see hospitalization) and no history of (-) DM, (-)HTN and (-)
Heart dse.
Hospitalization:
Date Findings
10/2016 d/t seizure
 Ancillary Procedure/Laboratory Exams:
Findings: Pt. unrecalled e procedures
FMHx:

Condition Father Mother

HTN (+) (+)
DM (-) (-)
Heart Dse. (-) (-)
Neurological d/o (-) (-)

Noted: Pt.’s uncle had diagnosed of cerebral palsy

MMHx:

Milestone:

Activities Normal yr to achieve Achieved Difference

Gross Unrecalled Unrecalled (+) supine to prone

(-) sitting

Fine Unrecalled Unrecalled (+) crude palmar grasp

Personal Social Unrecalled Unrecalled (-) recognition

Reflex sounds Unrecalled Unrecalled (+) cry

(+) laugh
(+) shouts

Talking Unrecalled Unrecalled (+) 2 syllables

(+) “mama”, “kuya”

Current Gross motor function:

(+) head control
(+) rolling
(-) trunk control
(-) crawl

Current fine motor function

 (-) handedness
(-) hand to mouth
(-) grasp

Language

(-) babble

PSE Hx:
Pt. c mother in a bungalow type house
BR- CR ~ 5m
BR- kitchen ~2m
BR- MD ~2m
Bed height- ~ 20 in high
Soft mattress
Sleep- prone

Goal : Mother’s Pt. stated that “ sana gumaling na anak ko”

O:

VS:
BP: 120/70mmHg
PR: 75 bpm
RR: 40 cpm
T: 36.20C

OI:
Manner of Arrival: W/C bound
Physique: Ectomorph
Mental Status: allert/incoherent/uncooperative
(+) Drooling
(+) Postural Deviation (see PA)
(+) bird wing deformity
(+) Hallux valgus L
(+) Hallux varus R
(+) Pes valgus B feet
(-) trophic skin changes
(-) swelling
(-) eye deformity
(-) eye symmetry
(-) facial assymetry
(-) strap hanger sign
(-) bird wing deformity
 (-) frog leg deformity
(-) windswept deformity

Palpation:
Thermal Assessment: Hypothermic
Tone Assessment: Hypertonic
(+) Muscle Spasm
(+) Tightness
(+) Spasticity
(+) Contracture
(-) Edema
(-) Tenderness
Back Assessment
(+) cervical&lumbar curve
(-) rib hump, scolio

Sensory Testing:

Sig: Pt
Neurologic Examination:

Sensory Testing: N/A

Device Used: Pin for pain, brush for light touch, thumb for P, two test tubes with hot
and cold water for temperature.

DTR’s:

R L

+++ +++
++ Legend:
+++ +++ Grade 0 areflexia
++ ++ Grade 1+ hyporeflexia
Grade 2+ normoreflexia
Grade 3+ hyperreflexia
+++ +++ Grade 4+ clonus

++++ ++++

Findings: Hyperreflexia on (B) UE/LE except: triceps tendon has a normoreflexia, ankle has a clonus
Significance: 2° to spasticity
ROM:
Reflexes:

(+) Babinski
(+) Cross extension reflex
(+) Withdrawal reflex
(+) Gordons reflex

Findings: Persistent primitive reflexes

Sig: 2o delayed developmental milestone

ROM

Motions of (B) UE/LE, neck and trunk were assessed actively, pain-free and are WNL

Note: PROM was not assess d/t pt.’s refusal

AROM was assess during play therapy

LEG LENGTH MEASUREMENTS

LLM Reference point (R) (L) Difference

TLL ASIS to med malleolus 51 cm 52 cm 1 cm
ALL Umbilicus to med. malleolus 55 cm 57cm 2 cm

Sig: (L) Lower Extremity is higher than the (R) 2° to bone shorthening

Postural Analysis (PA):

Posterior Anterior
(R) sh is slightly higher than the (L) (L) knee is higher than (R) knee
(R) lower angle of scapula is slightly higher than L (L) clavicle is prominent than the (R)

Sig: Poor body mechanics 2° to compensatory posture

FUNCTIONAL ASSESSMENT

7- Complete independence
6- Modified independence
5- Supervision
4- Min. Assistance
3- Mod. Assisstance
2- Max. Asssisstance
1- Total Assisstance/ Not testable
ADL GRADE

Self care
 Feeding 1
 Grooming 1
 Bathing 1
 Upper garment dressing 1
 Lower garment dressing 1

Sphincter control
 Bladder Mx 1
 Bowel Mx 1
Mobility
 Bed mobility 1
 Chair mobility 1
 Toileting 1
 Transfer 1
Locomotion
 Gait 1
 Expression 1
Communication
 Comprehensive 1
 Expression 1
Social Cognition
 Social interaction 1
 Memory 1
 Problem solving 1

Significance: Pt. has total assistance to perform ADLs independently 2o developmental delay.

A:

PT Impression: Pt. has total assistance in ding ADL’s such as self-care, sphincter control,
mobility, locomotion, communication, and social cognition d/t
developmental delay 2° cerebral palsy
Procedural Intervention: PT proposes a preventative intervention, since the pt. condition’s
intervention upon rehab is to avoid further complications on motor aspect
of the pt.
Rehabilitation Prognosis: Pt has good prognosis since pt. is under growth stage of development
therefore there is improvement with regard to the conditions

Problem List:
Problem List STG(24tx session x 3x a wk) LTG( 2 years)
1. Pt. has a total To increase from total To attain e possible N ADLs
assistance to perform assistance to supervision ADLs independently.
 ADLs independently independently
20 developmental
delay
2. Pt has abnormal Pt will improve & maintain Pt will achieve near normal
posture body posture p 3mos tx posture p 6 mos tx session
session

PT Mx:
No PT Mx. was given

Suggested Mx:

1. ES on (L) UE/LE
2. PROME c stretching at end range
3. Play therapy
4. Tilt table
5. FES to (R) UE/LE
6. PREs to (R) UE/LE

Precaution: Fall , BP