You are on page 1of 6

Name: Pacupac, Sapphire Joy O.

Age: 6 y/o

CRS PEDIATRIC CLINIC 2016
Diagnosis: Cerebral Palsy
Clinic: CRS

Fatherborne . 2. OD 5. A> Patient was seen and treated today. . OD 4. MANAGEMENT GIVEN: Sit to Stand Exercises x 10 reps x 1 set. Bridging exercise x 10 seconds hold x 10 reps x 1 set.5 . 3. Coherent and Cooperative . . The goal for today was achieved. The patient was able to stand with manual support on hands for 26 seconds during sit to stand exercises and tolerate ambulation inside the clinic with (25%) manual contact on (B) hands inside the clinic for 5 rounds. P> Continue same management next session. . OI: . OD REACTION TO TREATMENT: Patient was able to tolerate management without any adverse effects. Phyllis Yna G. Add NDTs for crawling next session.(-) Preferred arm posture Before 82 17 36. DLSHSI PT Intern PT NOTES June 16. OD Ball Kicking with 1 lbs Ankle weights on (B) LE x 10 reps x 2 set.Alert. OD Standing Balance with (25%) manual contact on Pelvis x 10 minutes x 1 set. Ambulation inside the clinic with (25%) manual contact on (B) hands x 5 rounds x 1 set. OI: . 2016 GOAL FOR TODAY: to ambulate for 5 rounds inside the clinic without an S> No New complaints O> (See Vs Chart) All WNL Vital Signs BP HR (bpm) RR (cpm) Temp . .(+) Sialorrhea .6 After 78 17 36.Fatherborne .PT NOTES Assistive device June 09.2 . . 2016 manual contact on (B) GOAL FOR TODAY: To ambulate inside the clinic for 5 rounds with (25%) Hands S> No New complaints O> (See Vs Chart) All WNL Vital Signs Before BP HR (bpm) 88 RR (cpm) 22 Temp 36.5 PT 1. Patient cooperated during all the exercises because her sister helped her in doing the exercises. . . Herradura. .(+) Sialorrhea After 95 28 36.

Bridging exercise x 10 seconds hold x 10 reps x 1 set. Patient was able to stand without manual support for 30 seconds during standing balance exercise. OD 4. The patient was able to ambulate inside the clinic for 5 rounds with (25%) Manual contact on (B) hands P> Continue same management next session. Tall kneeling balance and tolerance with manual contact on (B) knees x 10 minutes x 1 set..1 PT MANAGEMENT GIVEN: 1. Side-lying on (B) sides with weight bearing on one extremity with relaxation on trapezius muscles x 10 minutes x 1 set. Goal was achieved. Coherent and Cooperative . OD . Bridging exercise x 10 seconds hold x 10 reps x 1 set.(-) Preferred arm posture After 87 19 36. . OD 3. OD 4. Herradura.(-) Preferred arm posture PT 1. Crawling exercises with manual assist on (B) UE and LE on 2 green mats x 2 rounds x 1 set. OD 6. Focus on crawling exercises. Phyllis Yna G. OI: . .Fatherborne . . OD 5. Reaching activities with trunk rotation on (B) side using ball x 10 reps on each side x 1 set. . GOAL FOR TODAY: To weight bear on (B) knees in kneeling position and muscles of the body in side-lying position in preparation S> No New complaints O> (See Vs Chart) All WNL Vital Signs Before BP HR (bpm) 88 RR (cpm) 17 Temp 36. OD Standing Balance with (25%) manual contact on Pelvis x 10 minutes x 1 set. 2. Patient would not provide active movements during crawling exercise and the PT would manually move her LE and UE reciprocally to simulate the patterns used in crawling. A> Patient was seen and treated today. OD Ball Kicking with 1 lbs Ankle weights on (B) LE x 10 reps x 2 set. OD 2. Patient cooperated during all the exercises because her sister helped her in doing the exercises.(+) Sialorrhea . . OD REACTION TO TREATMENT: Patient was able to tolerate management without any adverse effects. 3. Patient was having a hard time tolerating exercises in crawling.0 . . DLSHSI PT Intern PT NOTES June 21. Ambulation inside the clinic with (25%) manual contact on (B) hands x 5 rounds x 1 set.Alert. 2016 to activate lateral for crawling. MANAGEMENT GIVEN: Sit to Stand Exercises x 10 reps x 1 set.

Crawling exercises with manual assist on (B) UE and LE on 2 green mats x 2 rounds x 1 set. . The lateral flexors of the patient was contracting together with the contraction of the trapezius muscle on (B) sides of the body. S> No New complaints O> (See Vs Chart) All WNL Vital Signs Before After BP HR (bpm) 81 84 RR (cpm) 22 20 Temp 36. A> Patient was seen and treated today.REACTION TO TREATMENT: Patient was able to tolerate tall kneeling with manual contact on (B) knees but with accasional trunk bending or leaning on the therapist.4 36. DLSHSI PT Intern PT NOTES June 23. . OD 2. Always palpate for the contraction of scapular muscles during reaching activities. 2016 GOAL FOR TODAY: To weight bear on (B) knees in kneeling position and to activate lateral muscles of the body in side-lying position in preparation for crawling in 5 minutes. Try to make the patient focus on her exercises and relax patient’s muscles when in kneeling and side-lying position. Phyllis Yna G. PT would position patient in side-lying and stabilize (B) LE with the PT’s LE for her not to position self in prone. OI: . Goal was not achieved. OD 3. P> Continue same management next session. . . OD 4. OD 5. Goal for next session is the same. Patient was not able to tolerate side-lying with weight bearing on one side because patient would always want to position self in prone then sitting when positioned in side-lying.(-) Preferred arm posture PT MANAGEMENT GIVEN: 1. Upon palpation during Side-lying (B) sides with weight bearing on one extremity.(+) Sialorrhea .Alert. Bridging exercise x 10 seconds hold x 10 reps x 1 set. . Patient is still not used to do new exercises. Coherent and Cooperative .(+) Lateral curvature of the spine to the (R) . Standing balance and tolerance with (25%) manual contact on Pelvis with Reaching activities with trunk rotation on (B) side using ball x 15 minutes x 1 set. Patient was also able to tolerate side-lying position on (B) sides with manual support on Pelvis from PT’s LE. Herradura. Tall kneeling balance and tolerance while playing using different colored balls in a Green small table x 5 minutes x 1 set. OD REACTION TO TREATMENT: Patient was able to tolerate tall kneeling without support while doing table top activities. Side-lying on (B) sides with weight bearing on one extremity with relaxation on trapezius muscles x 10 minutes x 1 set. Patient tolerated sit to stand . .0 .Fatherborne .

Tall kneeling balance and tolerance while playing using different colored balls in a Green small table x 5 minutes x 1 set. . Herradura. Coherent and Cooperative . Phyllis Yna G. Goal for next session is the same. OI: .7 36. Manual assist is needed during crawling because patient would easily lost attention in doing exercise and position self in supine.exercises and was able to stand without support for 1 minute. Sit to stand exercises with (25%) manual contact on (B) Hands x 10 reps x 1 set. OD 6. Patient still is passive during crawling exercises. DLSHSI PT Intern PT NOTES June 28. Crawling exercises with manual assist on (B) UE and LE on 2 green mats x 2 rounds x 1 set. Goal was achieved. Patient have active movement during crawling by kicking her LE. P> Continue same management next session. Patient is easily distracted in doing bridging exercises. 2016 GOAL FOR TODAY: To crawl for 5 rounds in 2 green mats with manual assist on (B) UE and LE S> No New complaints O> (See Vs Chart) All WNL Vital Signs Before After BP HR (bpm) 85 90 RR (cpm) 28 22 Temp 36. Bridging exercise x 10 seconds hold x 10 reps x 1 set. Side-lying on (B) sides with weight bearing on one extremity with relaxation on trapezius muscles x 10 minutes x 1 set.0 . . . . Goal for next session is to correct pattern during crawling and correct posture during sitting. Patient crawled for 5 rounds in 2 green mats with manual assist on (B) UE and LE P> Continue same management next session. OD 5. . A> Patient was seen and treated today. OD 3. OD REACTION TO TREATMENT: Patient was given all the exercises without adverse effects. Focus on standing with rotational movements of the trunk and Improve NDts for patient’s crawling. B> Patient was seen and treated today. . .(-) Preferred arm posture PT MANAGEMENT GIVEN: 1. OD 2. OD 4. Goal was achieved. Herradura.(+) Sialorrhea . Patient was able to tolerate independent kneeling position and side-lying position with manual stabilization from PT with less episodes of positioning self in Prone. Phyllis Yna G.(+) Lateral curvature of the spine to the (R) . Standing balance and tolerance with (25%) manual contact on Pelvis with Reaching activities with trunk rotation on (B) side using ball x 15 minutes x 1 set.Alert.Fatherborne .

DLSHSI PT Intern .