Name: Pacupac, Sapphire Joy O.

Age: 6 y/o

CRS PEDIATRIC CLINIC 2016

Diagnosis: Cerebral Palsy
Clinic: CRS

PT NOTES
Assistive device
June 09, 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
;
; OI:
; - Fatherborne
; - (+) Sialorrhea
; - (-) Preferred arm posture

Before
82
17
36.6

After
78
17
36.5

PT
1.
2.
3.

MANAGEMENT GIVEN:
Sit to Stand Exercises x 10 reps x 1 set, OD
Ball Kicking with 1 lbs Ankle weights on (B) LE x 10 reps x 2 set, OD
Standing Balance with (25%) manual contact on Pelvis x 10 minutes x 1
set, OD
4. Bridging exercise x 10 seconds hold x 10 reps x 1 set, OD
5. Ambulation inside the clinic with (25%) manual contact on (B) hands x 5
rounds x 1 set, OD
REACTION TO TREATMENT:
Patient was able to tolerate management without any adverse effects. Patient
cooperated during all the exercises because her sister helped her in doing the
exercises.
A> Patient was seen and treated today. 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. The goal for today was
achieved. Add NDTs for crawling next session.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
June 16, 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
36.2
;
; OI:
; - Fatherborne
; - Alert, Coherent and Cooperative
; - (+) Sialorrhea

After
95
28
36.5

- (-) Preferred arm posture

PT
1.
2.
3.

MANAGEMENT GIVEN:
Sit to Stand Exercises x 10 reps x 1 set, OD
Ball Kicking with 1 lbs Ankle weights on (B) LE x 10 reps x 2 set, OD
Standing Balance with (25%) manual contact on Pelvis x 10 minutes x 1
set, OD
4. Bridging exercise x 10 seconds hold x 10 reps x 1 set, OD
5. Ambulation inside the clinic with (25%) manual contact on (B) hands x 5
rounds x 1 set, OD
6. Crawling exercises with manual assist on (B) UE and LE on 2 green mats x
2 rounds x 1 set, OD
REACTION TO TREATMENT:
Patient was able to tolerate management without any adverse effects. Patient
cooperated during all the exercises because her sister helped her in doing the
exercises. Patient was able to stand without manual support for 30 seconds
during standing balance exercise. Patient was having a hard time tolerating
exercises in crawling. 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. Goal was achieved. 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. Focus on crawling exercises.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
June 21, 2016
to activate lateral
for crawling.

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
36.0
;
; OI:
; - Fatherborne
; - Alert, Coherent and Cooperative
; - (+) Sialorrhea
; - (-) Preferred arm posture

After
87
19
36.1

PT MANAGEMENT GIVEN:
1. Tall kneeling balance and tolerance with manual contact on (B) knees x 10
minutes x 1 set, OD
2. Side-lying on (B) sides with weight bearing on one extremity with
relaxation on trapezius muscles x 10 minutes x 1 set, OD
3. Bridging exercise x 10 seconds hold x 10 reps x 1 set, OD
4. Reaching activities with trunk rotation on (B) side using ball x 10 reps on
each side x 1 set, OD

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. 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. PT would position patient in side-lying and stabilize (B) LE with the
PTs LE for her not to position self in prone.
A> Patient was seen and treated today. Goal was not achieved. Patient is still
not used to do new exercises. Upon palpation during Side-lying (B) sides
with weight bearing on one extremity, The lateral flexors of the patient
was contracting together with the contraction of the trapezius muscle on
(B) sides of the body.
P> Continue same management next session. Goal for next session is the
same. Try to make the patient focus on her exercises and relax patients
muscles when in kneeling and side-lying position. Always palpate for the
contraction of scapular muscles during reaching activities.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
June 23, 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.
S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP
HR (bpm)
81
84
RR (cpm)
22
20
Temp
36.4
36.0
;
; OI:
; - Fatherborne
; - Alert, Coherent and Cooperative
; - (+) Sialorrhea
; - (+) Lateral curvature of the spine to the (R)
; - (-) Preferred arm posture
PT MANAGEMENT GIVEN:
1. Tall kneeling balance and tolerance while playing using different colored
balls in a Green small table x 5 minutes x 1 set, OD
2. Side-lying on (B) sides with weight bearing on one extremity with
relaxation on trapezius muscles x 10 minutes x 1 set, OD
3. Bridging exercise x 10 seconds hold x 10 reps x 1 set, OD
4. 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, OD
5. Crawling exercises with manual assist on (B) UE and LE on 2 green mats x
2 rounds x 1 set, OD
REACTION TO TREATMENT:
Patient was able to tolerate tall kneeling without support while doing table
top activities. Patient was also able to tolerate side-lying position on (B) sides
with manual support on Pelvis from PTs LE. Patient tolerated sit to stand

exercises and was able to stand without support for 1 minute. Patient still is
passive during crawling exercises.
A> Patient was seen and treated today. Goal was achieved. 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.
P> Continue same management next session. Goal for next session is the
same. Focus on standing with rotational movements of the trunk and
Improve NDts for patients crawling.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
June 28, 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
36.7
36.0
;
; OI:
; - Fatherborne
; - Alert, Coherent and Cooperative
; - (+) Sialorrhea
; - (+) Lateral curvature of the spine to the (R)
; - (-) Preferred arm posture
PT MANAGEMENT GIVEN:
1. Tall kneeling balance and tolerance while playing using different colored
balls in a Green small table x 5 minutes x 1 set, OD
2. Side-lying on (B) sides with weight bearing on one extremity with
relaxation on trapezius muscles x 10 minutes x 1 set, OD
3. Bridging exercise x 10 seconds hold x 10 reps x 1 set, OD
4. 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, OD
5. Sit to stand exercises with (25%) manual contact on (B) Hands x 10 reps x
1 set, OD
6. Crawling exercises with manual assist on (B) UE and LE on 2 green mats x
2 rounds x 1 set, OD
REACTION TO TREATMENT:
Patient was given all the exercises without adverse effects. Patient have
active movement during crawling by kicking her LE. Manual assist is needed
during crawling because patient would easily lost attention in doing exercise
and position self in supine. Patient is easily distracted in doing bridging
exercises.
B> Patient was seen and treated today. Goal was achieved. Patient crawled
for 5 rounds in 2 green mats with manual assist on (B) UE and LE
P> Continue same management next session. Goal for next session is to
correct pattern during crawling and correct posture during sitting.
Herradura, Phyllis Yna G.

DLSHSI PT Intern