Name: Quinto, Rodel

Age: 11 y/o

CRS PEDIATRIC CLINIC 2016

Diagnosis: CP Mixed with Intellectual
Disability and Epilepsy
Clinic: MOC

PT NOTES
with manual
June 13, 2016

GOAL FOR TODAY: To Tolerate standing with PKS on (B) Knees for 5 minutes

Contact on (B) Shoulders

S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP
HR (bpm)
96
105
RR (cpm)
25
28
Temp
36.8
35.4
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Bite mark on posterior aspect of the Neck
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT MANAGEMENT GIVEN:
1. GPS on (B) Hip flexors in prone/side-lying x 30 seconds hold x 10 reps x 1
set, OD
2. Bridging Exercise with manual contact on (B) LE and facilitation on
stomach x 10 reps x 1 set, OD
3. Cross sitting with GPS on Pectoralis Major mm x 30 seconds hold x 10 reps
x 1 set, OD
4. Sustained Stretching on (B) Knees towards extension x 30 seconds hold x
3 reps x 1 set, OD
5. Standing balance and tolerance with PKS on (B) Knees x 5 minutes x 1 set,
OD
REACTION TO TREATMENT:
Patient was given all tx without any adverse effects. Pt. Tolerated standing for
3 minutes only due to tightness of (B) LE and Poor Trunk control
A> Goal for today was not achieved due to less time tolerated during
standing.
P> Continue same management next session. Goal for next session is same.

Herradura, Phyllis Yna G.

DLSHSI PT Intern
PT NOTES
June 15, 2016

GOAL FOR TODAY: To Tolerate sitting without support for 5 minutes

S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
80/70
80/70
HR (bpm)
82
85
RR (cpm)
23
32
Temp
35.6
36.5
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD
Sitting balance and tolerance without support x 5 minutes s 1 set, OD
Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth)

REACTION TO TREATMENT:
Patient was given all tx without any adverse effects. Pt. was not able to
tolerate unsupported sitting for 5 minutes with proper body mechanics due to
poor trunk control.
A> Goal for today was not achieved due to decrease tolerance in unsupported
sitting. Pt. was able to do it only for <2 minutes
P> Continue same management next session. Focus on developing trunk
control and correcting Pt.s posture in sitting. Promote weight shifting and
joint pounding during sitting. Goal for next session is to tolerate supported
sitting with proper body mechanics with weight shifting and weight
bearing on (B) Hands.
Herradura, Phyllis Yna G.

DLSHSI PT Intern
PT NOTES
with weight

GOAL FOR TODAY: to tolerate supported sitting with proper body mechanics
to tolerate supported sitting with proper body mechanics with

weight shifting and

June 17, 2016

weight bearing on (B) Hands for 5 minutes

S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
80/70
80/70
HR (bpm)
95
82
RR (cpm)
22
28
Temp
35.4
36.4
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT
1.
2.
3.

MANAGEMENT GIVEN:
PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD
Sitting balance and tolerance with support at the back and (B) LE x 5
minutes s 1 set, OD
4. Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth) x 10 reps x 1 set, OD
REACTION TO TREATMENT:
Pt. was given all the management without any adverse effect. Pt. was able to
tolerate sitting with support on his shoulder and LE for 5 minutes. Pt. also
tolerated sensory integration management with the use of cold spoon on his
mouth by closing his mouth and decreased tongue thrusting to 75% of the
time.

A> Goal for today was achieved. Patient tolerated sitting with support on his
shoulder and LE for 5 minutes with proper body mechanics and weight
shifting and weight bearing on (B) Hands
P> Continue same management next session. Goal for next session is the
same. Increase repetitions and include Holds during sensory integration
treatment.

PT NOTES
with weight

Herradura, Phyllis Yna G.

DLSHSI PT Intern
GOAL FOR TODAY: to tolerate supported sitting with proper body mechanics
to tolerate supported sitting with proper body mechanics with

weight shifting and

June 20, 2016

weight bearing on (B) Hands for 5 minutes

S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
100/70
100/70
HR (bpm)
88
106
RR (cpm)
20
22
Temp
36.4
36.5
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT
1.
2.
3.

MANAGEMENT GIVEN:
PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD
Sitting balance and tolerance with support at the back and (B) LE x 5
minutes s 1 set, OD
4. Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth) x 10 seconds hold x 10 reps x 1 set, OD
REACTION TO TREATMENT:

Pt. was given all the management without any adverse effect. Pt. was able to
tolerate cross sitting with support on the back and LE together with joint
pounding Pt. also tolerated sensory integration management with the use of
cold spoon on his mouth by closing his mouth and decreased tongue
thrusting to 75% of the time.
A> Goal for today was achieved. Patient tolerated sitting with support on his
shoulder and LE for 5 minutes with proper body mechanics and weight
shifting and weight bearing on (B) Hands
P> Continue same management next session. Goal for next session is to
increase repetitions and include Holds during sensory integration
treatment.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
with weight

GOAL FOR TODAY: to tolerate supported sitting with proper body mechanics
to tolerate supported sitting with proper body mechanics with

weight shifting and

June 20, 2016

weight bearing on (B) Hands for 5 minutes

S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
100/70
100/70
HR (bpm)
88
106
RR (cpm)
20
22
Temp
36.4
36.5
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT MANAGEMENT GIVEN:
1. PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
2. GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD

3. Sitting balance and tolerance with support at the back and (B) LE x 5
minutes s 1 set, OD
4. Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth) x 10 seconds hold x 10 reps x 1 set, OD
REACTION TO TREATMENT:
Pt. was given all the management without any adverse effect. Pt. was able to
tolerate cross sitting with support on the back and LE together with joint
pounding but patient would still move to different position during sitting Pt.
also tolerated sensory integration management with the use of cold spoon on
his mouth by closing his mouth and decreased tongue thrusting to 75% of the
time.
A> Goal for today was achieved. Patient tolerated sitting with support on his
shoulder and LE for 5 minutes with proper body mechanics and weight
shifting and weight bearing on (B) Hands
P> Continue same management next session. Goal for next session is to
Promote unsupported sitting and to increase repetitions and include Holds
during sensory integration treatment.
Herradura, Phyllis Yna G.
DLSHSI PT Intern

PT NOTES
GOAL FOR TODAY: to tolerate unsupported sitting with proper body
mechanics with weight
to tolerate supported sitting with proper body mechanics with
weight shifting and
June 22, 2016
weight bearing on (B) Hands for 5 minutes
S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
120/70
110/70
HR (bpm)
87
100
RR (cpm)
30
23
Temp
36.0
36.4
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Bite mark on (L) posterior side of the arm
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi
-Head is titled to the
-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis

Significance: Pt. would have difficulty in assuming an upright sitting

position. Posture correction and stretching of muscles should be
incorporated during tx.

PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD
Sitting balance and tolerance without support x 5 minutes s 1 set, OD
Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth) x 10 seconds hold x 10 reps x 1 set, OD

REACTION TO TREATMENT:
Pt. was given all the management without any adverse effect. Pt. was not
able to tolerate sitting without support for 5 minutes due to poor trunk
control and athetosis. Pt. would still independently but with poor body
mechanics in sitting and would fall down in a few minutes. Pt. would still need
2 therapist to stabilize (B) LE and the Shoulder to sit upright and weight bear
on (B) Hands. Sensory integration tx was not given due to lack of ice in the
kitchen.
A> Goal for today not achieved. Pt. still needs assistance during sitting.
P> Continue same management next session. Incorporate NDTs to improve
trunk control on management and Sensory integration treatment. Goal for
next session is to tolerate unsupported sitting with proper body mechanics
and Weight shifting together with Weight bearing on (B) Hands for 5
minutes.
Herradura, Phyllis Yna G.
DLSHSI PT Intern

PT NOTES
GOAL FOR TODAY: to tolerate unsupported sitting with proper body
mechanics with weight
to tolerate supported sitting with proper body mechanics with
weight shifting and
June 24, 2016
weight bearing on (B) Hands for 5 minutes
S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP (mmHg)
110/80
110/70
HR (bpm)
95
87
RR (cpm)
16
21
Temp
36.2
35.8
?
? OI:
? - Wheelchair Bound, Non-ambulatory
? - Ectomorph
? - Pt. is lethargic 70% of the time
? - Not in apparent pain and respiratory distress
? - (+) Sialorrhea
? - (+) Tongue Thrusting
? - (+) Open Mouth Posture
? - (+) Postural Deviation
? All bony landmarks are assessed in supine and sitting position and is WNL
except for:
Anterior
Lateral
Post
-(+) Rib bump
-Increased thoracic Kyphosis
-(L) Shoulder hi

-Head is titled to the

-(B) Knees Flexed
-(B) Ankle is ev
-(L) Shoulder higher than
-(B) Ankles plantarflexed
-Lateral curvatu
- Hand ulnarly deviated wrist
towards the
-Rounded Shoulder
-(B) Ankle is everted
? Interpretation: (+) Postural deviation 2o to muscle tightness and scoliosis
? Significance: Pt. would have difficulty in assuming an upright sitting
position. Posture correction and stretching of muscles should be
incorporated during tx.
PT
5.
6.
7.
8.

MANAGEMENT GIVEN:
PROMEs on (B) UE and LE towards AP x 10 reps x 2 sets, OD
GPS on (B) LE towards AP x 30 Seconds Hold x 10 reps x 1 set, OD
Sitting balance and tolerance without support x 5 minutes s 1 set, OD
Sensory integration on the mouth (Ice cold water with spoon. Put the
spoon on Pt.s mouth) x 10 seconds hold x 10 reps x 1 set, OD

REACTION TO TREATMENT:
All tx was given without any adverse effect. Pt. was not able to tolerate
unsupported sitting due to poor trunk control and athethosis. Patient still
needs 2 PTs to stabilize Pt.s shoulder and LE for him to sit upright and
weight bear on (B) Hands. Pt. would occasionally sit upright but with poor
body mechanics will fall down after a few minutes.
A> Goal for today was achieved. Pt. tolerated sitting with support from Pt.
P> Continue same management next session. Incorporate NDTs to improve
trunk control on management and Sensory integration treatment. Goal for
next session is to tolerate unsupported sitting with proper body mechanics
and Weight shifting together with Weight bearing on (B) Hands for 5
minutes.
Herradura, Phyllis Yna G.
DLSHSI PT Intern