PEDIATRICS INITIAL EVALUATION

GENERAL INFORMATION

Pt.’s Name: PSJ

Age: 12 yrs old
Sex/Gender: Male
Address: Itaewon, Bulacan
Handedness: Right
Referring Unit: Pediatrics Department
Referring MD: Dr. Nam Joo-hyuk
Rehab MD: Dr. Lee Min Ho
Date of Referral: 03/1/2020
Date of IE: 03/4/2020
Diagnosis: DMD ( Duchenne Muscular Dystrophy )
Informant/Realibility: Mother ( Reliable )

Height: 150 cm
Weight: 63 kl
BMI: overweight

SUBJECTIVE INFORMATION

C/C (chief complaint):

“Nahihirapan po akong kumilos magisa lalo na pag aakyat ng hagdanan or kahit lalakad lang sa
malapit po. Pakiramdam ko din na para akong laging pagod saka parang nanghihina ung mga paa ko
po. Ang sabi po ng doctor may DMD daw po ako”

Translated :

Pt c/o difficulties in moving alone to different place and difficulty in climbing stairs. Pt also c/o of
fatigue and weakness on (B) LE. Pt was dx of DMD ( Duchenne Muscular Dystrophy )

Caretaker’s Goal:

To be able to move c use of AD and to lessen the difficulty in standing, walking, and climbing
stairs. To slow the progression of the symptoms of DMD such as mm weakness in (B) LE.

HPI (history of present illness):

This is a case of PSJ, a 12 years old born at complete term or gestation on December 04, 2008 to
a 28-years-old multigravida mother who gave birth through normal vaginal delivery at Sacred Heart
Hospital assisted by Dr. Song joong-ki.
Maternal Hx:

PRENATAL HISTORY
Drugs/Meds:
 Obimin plus 400 mg ( for vitamins )
 Clexane 20mg ( blood thinner )

Prenatal Care: Irregular Check-up (d/t busy schedule)

Attitude towards pregnancy: wanted
(-) DM
(-) trauma/ accidents
(-) smoker
(-) alcoholic drinker

PERINATAL HISTORY
 Complication: No complication
 Hours of labor: 7 hrs.
 Presentation: Cephalic
 Mode of delivery: Normal

POSTNATAL HISTORY
 Follow up check-ups
 Pediavites (vitamins)
 Lab/Exam Results:
o EMG (Electromyography) -interference pattern analysis revealed myopathic pattern in
the right vastus lateralis suggestive of primary muscle disease
o Laboratory Examination -Serological analysis showed creatine kinase (CK) level to be
elevated to 7342 U/L, lactate dehydrogenase to 595 μg/dl, and alanine transaminase
level to 124 U/L.
o Genetic testing – found that the defect was on maternal side of pt. ( family member
from the maternal side died on the same condition )

 Immunization : Completed ( Birth to 1 yrs old )

o BCG
o HEP B
o PCV
o INFLUENZA
o MEASLES
o HPV
o HEP A

Developmental Milestones Assessment

Milestone Normal Age of Age of achievement

Accomplishement
Newborn Flexor tone predominates Newborn
4 months Prone to supine 4 months
7 months Supine to prone 7 months
10 months Stand 10 months
Pivot in sitting
3 c’s
14 months Walk: Mid high guard 14 months
Wide BOS
Increase pelvic hip and knee flx
18 months Walk: low guard 18 years
Walks backward
2 years Running 2 years
Starts to climb stairs: step to
pattern
3 years Runs well 3 years
Climb stairs with alternating
feet
4 years SQUATS 4 years
HOPS
HEEL Walking
Underhand throw/catch
5 years SKIPS 4 years
Tip Toe
table tandem walking
Diagonal throw/catch
6 years – present Bi6cle Achieved but slowly having
Roller SKATES difficulty to do the activities
Mature throw/catch

Milestone Normal Age of Age of achievement

Accomplishement
Newborn Cry Achieved
4 months Coos & Chuckle Achieved
7 months Utter 1 syllable Achieved
10 months Utter 2 syllable Achieved
14 months Say 1 word Achieved
18 months Identify pictures Achieved
Points body parts
2 years 2 phrases Achieved
3 years 3 phrases Achieved
4 years Repeat 4 digits number Achieved
5 years Number 10 concept Achieved
6 years – present Mastery of grammar Achieved

Milestone Normal Age of Age of achievement

Accomplishement
Newborn Palmar grasp Achieved
 4 months Crude grasp Achieved
7 months Intermediate grasp Achieved
10 months Pincer grasp Achieved
14 months Crayon Holding : Whole end Achieved
scribbles
18 months Crayon Holding : But End Achieved
2 years Can draw vertical line Achieved
3 years Can draw circles Achieved
4 years Can copy cross Achieved
5 years Triangle Achieved
6 years Fat diamond Achieved
Significance: to determine pt’s developmental milestone to see if she has disability and what
intervention is appropriate for the tx.

OBJECTIVE

A. Vital Signs

Before During After

Temperature 36.5 37 36.7

RR 26 bpm 35 bpm 30 bpm
PR 83 bpm 85 bpm 85 bpm
BP 100/80 mmHg 110/90 mmHg 100/80 mmHg
Significance: for baseline purposes

B. Ocular Inspection
 Mother borne
 Body Built – W/D
BMI Categories:
Normal = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
 Head circumference (normocephalic) – 50cm
 Rushes on (B) Legs
 (+) ecchymosis (L) knee
 (+) Gait Deviation ( Wadling Gait
 (+) Gower Sign
 (+) Postural Deviation
 (-) Scars (LE & UE )
 (-) wounds ( knee )
C. Palpation
 Normothermic on all exposed body parts

 (+) Contracture on both knees

 (+) Spasticity on both hamstrings

 (+) Calf Pseudohypertrophy

D. Behavior
1. General Behavior
 Alert/ Cooperative/ Responsive
2. Play Behavior
 Participative
3. Favorite Toy
 Toy Cars
4. (+) Eye Contact
5. Stranger/Seperation Anxiety
 Friendly and cooperative
6. Attention Span
 constant
7. Concentration
 Good- not distracted and easily return without promting
8. Frustartion Tolerance
 Pt is aware of his disability and tries hard to complete task

E. NEUROLOGICAL EVALUATION
1. Tone assessment
 Spasticity ( B ) LE
 hypertonia

2. Sensory and perceptual skills

Sensory skills Stimulus Response

Tactile-light touch Brush strokes (lower limb) Normal
Tactile-Pain Pin prick, pinch (lower limb) Normal
Tactile-Pressure Thumb pressure (lower limb) Normal
Visual Threat Hand approximated Normal
towards pt’s face
Visual Localization Toy/Colored object Normal
Visual Tracking Toy/Colored object Normal
moved from (R) & (L)
direction
Auditory Localization Rattle placed behind Normal
pt’s ears
Auditory Tracking Rattle moved into (R) Normal
 & (L) direction
Findings: intact in all tested sensory and perceptual skills

3. Reflex Testing
Reflex Site of stimulus Normal response CNS segment
PATELLA Patellar tendon Leg extension L3-L4
MEDIAL HAMSTRING Semimem. tendon Knee flexion/ L5-S1
muscle contraction
LATERAL Biceps femoris Knee flexion/ L5-S1
HAMSTRING tendon muscle contraction

A. Muscle Stretch / Deep Tendon Reflex Reflex

++ ++
CV
++ ++

Significance: 2° joint contracture

+ +
Significance: hyporeflexia
+ +

B. Pathologic reflex

Pathologic Reflex Stimulus Response

Babinski Stroking of lateral aspect of sale of No extension of big toe and
foot fanning of four small toes, Normal
reaction in newborns
Clonus Dorsiflexion of the foot No cyclical, spasmodic alternation
of mm ctxn & relaxation

Significance: (-) Babinski/Clonus and for rule out purposes.

4. Hand Evaluation
 Right Handedness
 Prehension Pattern ( gross to fine )
- Good

5. Cognitive & Speech Evaluation

 Needs prompting
 Capable of motor stimulation
 Can verbalize concerns independently
  Able to identify body parts
 Words are comprehensible
F. Range of Motion

Region Normal Right Right Left Left End Feel

Value Passive N-P Passive N-P
HIP FLEXION 0°-120° 90° 30° 90° 30° Mushy
HIP EXTENSION 0°-20° 10° 10° 10° 10° Mushy
KNEE FLEXION 0°-135° 100° 35° 100° 35° Mushy
KNEE EXTENSION 0°-10° 8° 2° 8° 2° Mushy
ANKLE DORSIFLEXION 0°-20° 10° 10° 10° 10° Mushy
ANKLE 0°-50° 25° 25° 25° 25° Mushy
PLANTARFLEXION
Significance: LOM d/t contracture

G. Gross Motor Skill Assessment

 Level III
 Neck- maintained in midline
 UE- able to play and grasp object
 LE – unable to bear weight and shift alone

H. Functional Muscle Testing

 Weak Functional (WF)- moderate impairment or delay that affects activity pattern, base
of support or control against gravity or decrease functional exploration
o Pt.’s activity was limited and affects activity pattern such as walking, running
and moving alone.

I. Postural Analysis

All postural landmarks are viewed lateral in standing position

Landmarks Anterior Posterior Lateral

Head - - midline
Thoracic - - midline
Lumbar - - hyperextended
Pelvis - - -
Findings: Pt has a lumbar lordosis posture
Significance: 2°

J. Gait Analysis
 Pt. ambulates with waddling gait pattern

K. Activity of Daily Living Assessment

  Moderate - Difficulties on ADL & may require assistive device.

ASSESMENT

PT Diagnosis:
 Impaired Motor Function and Sensory Integrity Associated with Nonprogressive
Disorders of The Central Nervous System – Congenital Origin or Acquired in
Infancy or Childhood

Prognosis & Rehab. Potentials:

Pt. presents with fair prognosis. Pt. And his family was participative and willing to do home exercise
program and attend therapy schedules . Pt. presents willingness to participate in exercises program.

Problem List:

1. Mm weakness on (B) LE

2. Decrease Range of Motion

3. Contracture on (B) knee

4. Postural deviation

Short Term Goals (STG):

After 5-8 tx session of PT, the Px will be able to achieve the following:

1. Pt will be able to maintain mm strength by doing exercises

2. Minimize progression of contracture and deformity by stretching/exercise or with us of devices

3. Increase range of motion

Long Term Goals (LTG):

After 10-15 tx session of PT, the Px will be able to achieve the following:
 1. pt can stand and walk c assistance or modified AD for mobility

2. pt posture will improve

3. pt. gross motor skill improve such as walking, running and other ADL

4. Locomotion activities including ambulation skills (falling down, getting up), walk on
various terrains, transfer to various surfaces (chair, car, bed).

PLAN

Prescribed PT Mx:
 Early Intervention ( PT tx 2xweek)
 ES x 15min per area
 FES x 10 mins per area
 PROM exercise (LE)
 Play Therapy

Suggested PT Mx:
 Increase frequency of therapy per week
 Gait training 10min x rest x 10 mins (parallel bars/ parapodium)
 PROM exercise both ( LE)
 ADL retraining ( OT )
 Exercise for correcting posture

Prepared by: Gwyn Mari D. Concepcion