I.
General Information
Patients Name:
Age:
Sex:
Birthday:
Address:
Civil Status:
Handedness:
Occupation:
Religion:
Referring Doctor:
Referring Unit:
Rehab Doctor:
Date of Referral:
Date of Consultation:
Date of Evaluation:
Diagnosis:
Etilogy:
E. T.
11 y/o
Male
Febraury 28, 2006
Brgy. Payokpok, Baung, La Union
Single
(R)
none
Roman Catholic
Dr.J
OPD
none
none
October 2009
December 3, 2016
CP, (L) Spastic Hemiplegic
TB Meningitis
Subjective:
c/c: Hirap siyang gamitin yung kaliwang kamay niya tapos hindi siya masyadong makapagsalita.
PT Translation: Difficulty in using the (L) UE & difficulty to speak.
Informant/ Reliability: Mother
History of Present Illness:
Pt present condition started 11 yrs PTIE, when the pts mother took pills during the 1st trimester of her
pregnancy because she was not aware that she is pregnant. When the pt was born, he was cyanotic but
the informant stated that he looked normal the following yr.
10 yrs PTIE, the pt slipped & the back of his head was the first to hit the ground. Since then, pt had
difficulty using his (L) UE.
7 yrs PTIE, pts parents brought him to San fernando where she had a CT Scan in an LMC. Dr.J
diagnosed him with (L) Hemiplegic Cerebral Palsy 2 0 TB Meningitis. Dr.J prescibed a medicince for the
pts brain but the name of the drug is unrecalled. Since they dont have money for PT Tx, they just brought
the pt to a masseur.
Maternal Hx:
G3P3 (0-3-0-3)
Age of mother upon pregnancy: 36 y/o
(+) intake of pills on the 1st trimester of pregnancy
complete vaccinations
(-) check up
(-) ultrasound
Mother was not occupied at any job during pregnancy, sedentary lifestyle
Birth Hx:
AOG: 32 wks
Normal delivery with cephalic presentation in their house
APGAR Score: 7
Appearance= 0
Pulse= 2
Grimace= 2
Activity= 1
Respiration= 2
Head circumference N/A
Birth length: N/A
Birth wt: N/A
Nutritional Hx:
Pt was breastfed until 1 y/o
Bottlefed until 3 y/o
Semi solid on 2 y/o
Pt has a good appetite
Immunization Hx:
Complete vaccination
Development Milestones:
Milestone
Crawls
Stand
Ambulation
Speech (2-syllable
word)
Normal Age
9-10 mos
1 y/o
1 yr and 6 mos
6 mos
Chronological Age: 11 y/o
Chronological Age
Crawls
132 mos
Stand
11 y/o
Ambulation
132 mos
Speech
132 mos
Past Medical Hx:
(-) hospitalization
(-) consulation
(-) chickenpox
(-) measles
(-) pneumonia
(-) asthma
(-) infection
(-) allergies
Age Achieved
10 mos.
1 y/o
2 y/o
1 y/o
Developmental Age
10 mos
1 y/o
18 mos
12 mos
Age delayed
122 mos
10 y/o
114 mos
120 mos
Family Medical Hx:
CP
Father:
Mother:
(-)
(-)
HTN
(+)
(-)
Heart Disease
(+)
(-)
DM
(-)
(-)
Note: Pts siblings do not have CP.
Personal Social Environmental Hx:
Pt lives with her mother, elder brother and their other relatives in a 2-storey house with 7 flights of stairs.
She has a sedentary lifestyle but sometimes plays with her friends outside thier house. She is a nonsmoker and non-alcohol beverage drinker.
BR-LV: 3 steps
BR-CR: 6 steps
BR-DR: 4 steps
BR-Kitchen: 4 steps
OBJECTIVE INFORMATION
V.S:
B.P:
P.R:
R.R:
Temp:
90/80 mmHg
65 bpm
16 cpm
35.80C (Axillary T0)
OI:
Ambulatory
Coherent, cooperative
Brocas aphasic
Ectomorph
(+) drooling
(+) (L) tongue thrusting
(+) typical arm posture on (L) UE
(+) postural deviation (see PA)
(+) gait deviation (see GA)
(-) trophic skin changes
(-) swelling
(-) eye deformity
(-) eye symmetry
(-) facial assymetry
(-) strap hanger sign
(-) bird wing deformity
(-) frog leg deformity
(-) windswept deformity
Palpation:
Normothermia on all 4s
Hypertonia on (L) UE & LE
(+) spasm on (L) FA
(-) tenderness
(-) edema
(-) contracture
(-) crepitus
NEUROLOGIC EVALUATION:
Sensory Testing:
a. Tactile Testing:
Pain
o STD used: pin of the nuero-hammer for pain
o Response: grimace after pin pricked (B) FA
o Significance: intact sensory pathway
Light Touch
o STD used: brush of the nuero-hammer for light touch
o Response: pt looked at the part being stimulated
o Significance: intact sensory pathway
Deep Pressure:
o STD used: thumb of the examiner for deep pressure
o Response: pt looked at the part being stimulated
o Significance: intact sensory pathway
b. Auditory Testing: N/A
c. Visual Testing:
VTD used: Colorful stuffed toy
Localization: 1 foot away from the pt laterally moved from (R) to (L) and upwards
moving downwards
Tracking: Pt was able to follow the toy through her eye from (R) to (L) and upwards and
downwards
Significance: Intact BA 17, 18, 19
1. DTRs/ MSRs:
(R)
(L)
++
N/A
++
++
N/A
N/A
++
+++
++
Legend:
0
+
++
+++
++++
areflexia
hyporeflexia
normoreflexia
hyperreflexia
clonus
+++
Findings: Normoreflexia on (R) UE & LE, hyperreflexia on (L) LE but N/A on (L) UE 2 0 typical arm posture
Significance: Intact reflex arc on (R) UE & LE, impaired relfex arc on (L) LE 2 0 UMNL
2. Pathologic Reflex:
(+) Banbinski on (B) feet
3. Primitive Reflex: N/A
TONE ASSESSMENT
Pt has grade 3 muscle tone on (L) UE & LE.
Pt has grade 2 muscle tone on (R) UE & LE.
1
2
3
4
5
No response
Decrease in response
(Hypotonic)
Normal (normotonic)
Exaggerated response
(hypertonic)
Sustained response
SPASTICITY ASSESSMENT
Grade 3 flexor spasticity on (B) (L) UE & LE
Grade 0 spasticity on (R) UE
Legend: Modified Ashworth Scale
1- No increase in muscle tone
2- Slight increase in muscle tone manifested by a catch and release or by
minimal resistance when the affected parts is moved in flexion and extension
1+
Slight increase in muscle tone manifested by a catch followed by min
resistance throughout the remainder (less than half) of the ROM
3- Marked increase in muscle tone through most of ROM, but affected parts
easily moved
4- Considerable increase in muscle tone, passive movement difficult
5- Affected parts rigid in both flexion and extension
ROM:
All major jts of (R) UE & LE are WNL, done actively, pain-free.
Jts. of the (L) UE & LE are measured as follows:
Joints:
PROM:
Difference:
End-Feel:
Shoulder flex.
0-1800
0-1540
260
Empty
Shoulder ext.
0-600
0-500
100
Empty
Shoulder abd.
0-1800
0-1200
600
Empty
Empty
Elbow flex.
0-150
0-120
Hip flex.
0-1200
0-800
400
Empty
Hip ext.
0-300
0-280
20
Empty
0-42
30
Empty
Hip ER
0-45
Hip IR
0-450
0-400
50
Empty
Knee flex.
0-1350
0-700
650
Empty
Findings:
Sig:
MMT:
Findings:
Sig:
Normal ROM:
LOM on (L) UE & LE
LOM 20 pain
All major muscles of (R) UE & LE are grossly graded 3/5
All major muscles of (L) UE & LE are grossly graded 2/5.
Muscle weakness 20 immobility
RGR:
Reach
Grasp
Release
(R)
(+)
(+)
(+)
(L)
(-)
(-)
(-)
Legend:
Poor: (-) reach, (-) grasp, (-) release
Fair: (+) reach & grasp, difficulty in release or (+) reach
& release with difficulty in grasp or (+) reach & difficulty
in (B) grasp & release
Good: complete RGR
Findings: Pt has good RGR on (R) hands but poor RGR on (L) hands.
LEG LENGTH MEASUREMENTS
Reference point
ASIS to med malleolus
Umbilicus to med. malleolus
(R)
28 inches
27 inches
(L)
28 inches
27 inches
Difference
0
0
Special Test (ST)
Babinki Reflex
Findings:
(+) fanning of toes & extension on big toe on (B) foot
Sig:
(+) Babinski sign on (B) LE 20 UMNL
Postural Analysis (PA):
Findings:
View: Anterior
Landmark
Head
Shoulder
Inf. Border of the spine of the
scapula
Pelvis
Sig:
(R)
(L)
In neutral
In neutral
higher
In neutral
higher
In neutral
(+) postural deviation 20 typical arm posture
Gait Analysis (GA):
Findings: (+) (L) pelvic drop during ambulation
Significance: (+) Trendelenburg Gait 20 weak gluteus medius
Step Length
Stride Length
FIM:
(R)
8 inches
17.5 inches
(L)
7.5 inches
17.5 inches
Pt is graded 3 on self-care activities such as feeding, grooming, dressing, bathing and toileting.
Pt is graded the ff on bed mobility:
Roll to left:
7
Roll to Right:
4
Supine to Sit:
7
Sit to Supine:
7
Pt is graded 7 on transfers such as bed to chair & sit to stand.
Pt is graded 7 on ambulation.
Sitting/Standing Balance Tolerance
Balance:
Tolerance:
Legend:
0
P
F
G
N
Assume:
+
+
+
+
Sitting:
Standing:
Maintain:
+
+
+
Weight-Shifting:
+
+
Challenge:
+
Findings: Fair Tolerance in short Sitting
ASSESSMENT:
PT Impression: LOM on (L) UE & LE and muscle weakness on (B) UE & LE 2 0 typical arm posture, pain
and immobility.
Problem List:
PLAN:
Suggested PT Mx:
HIP:
1. Pt and family education
2. Proper body mechanics
3. Energy conservation techniques
