Initial Evaluation

General Information
Patients Name: J.P.H
Age:
14 y/o
Sex:
Male
Address:
zone 1, lingsat, City of San Fernando, La Union
Civil Status:
single
Citizenship:
Filipino
Handedness:
Occupation:
Religion:
Catholic
Referring Unit:
Referring Dr.:
Rehab Dr.:
Date of Referral:
Attending Dr.:
Dr. N.R.
Date of Consultation: unrecalled
Date of Evaluation:
December 2, 3016
Diagnosis:
Cerebral Palsy
Informant: Mother
S:
c/c:
Hindi sila makatayo, hildi niya magalaw paa niya, wala ganyan na siya dati
HPI:
Pt.s mother states that the condition started 14 years ago when she was pregnant ( 6mos. And
18 days) and notice some spotting, then pts mother decided to rush on Provincial Hospital.
Unexpectedly J.P.H. was delivered normal. d/t premature pt. has in incubator for last 9 months.
In past months and years pt mother notice no balance, no supine to prone and no crawling.
Contracture on B LE and (L) on his 2 yr old and the contracture was worsen d/t to no treatment or
exercise.
Pt. has no medicines nor vitamins taking. Pt started using w/c when patient gets heavier.
Present condition pt. is w/c bound. Cant perform any ADLs and total dependence.
Developmental Hx:
Developmental milestones
Gross:
(+) supine to prone
(-) sitting
Fine
(+) crude palmar grasp
Personal Social
(-) recognition
Reflex sounds
(+) cry
(+) laugh
(+) shouts
Talking
(+) 2 syllables

(+) mama, kuya

Current Gross motor function:
(+) head control
(+) rolling
(-) trunk control
(-) crawl
Current fine motor function
(-) handedness
(-) hand to mouth
(-) grasp
Language
(-) babble
Education
None
PMHx:
Pt. has no previous hx of hospitalization or any surgery.
FMHx:
M
(+)

Heart
Disease
Goiter
Asthma
HTN
CP
DM

(+)
(-)
(-)
(-)
(-)

PSHx:
Pt has sedentary lifestyle and lives on a bungalow type of house with his mother. Pt
is non smoker and alcoholic beverage drinker. Pt sleeps in a soft matress and sleeps in
prone.
HOME DIMESION:
BR, CR ~ 5m
BR, kitchen ~2m
BR, MD ~2m
Bed height, ~ 20 in high

Goal:

sana kahit maibend lang niya mga paa niya

O:
VS:
BP: 120/70 mmHg
PR: 75 bpm
RR: 40 cpm
T: 36.2 C

OI
Manner or arrival: w/c bound
Mental status: A/C
Physique: Endomorph
(+) Claw Toes
(+) Flat Foot
(+) Hallux Valgus (L) LE
(+) hallux Varus on LE
(+) Pes Valgus on (B) feet
(+) Contractures
(-) Swelling
(-) Trophic skin changes
(-) Gait Deviation
(-) Deformities
(-) Digital Clubbing
Palpation:
Thermal Assessment: Normothermic
Tone Assessment: Hypotonic on LE
(+) Cervical Curves
(+) Lumbar Curves
(-) Rib humps
(-) Scoliosis
(-) Tenderness
(-) Muscle Spasm
(-) Edema
Neurologic Evaluation:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for deep pressure
Findings: N/A
Significance: N/A
DTR:
R

Significance: Impaired reflex arc d/t affectation o UMNL

POSTURAL REFLEX:
FINDINGS:
(+) HNR
(-) GR
(-) Moro

++

SIG.:
Affectation on UMNL
ROM:
Findings:
Motion

Differenc
e
(PROM)

END FEEL

AROM

PROM

NORMAL

Differenc
e (AROM)

115

135

135

15

Soft

130

180

180

50

Firm

40

70

70

30

Firm

60

90

90

30

firm

L elbow
flex
L sh. Flex

R sh IR
0
R wrist
0
flex
Significance: d/t contractures
MMT:
Findings:
L elbow flex
L sh. Flex
R sh IR
R wrist flex

Grade
1/5
1/5
1/5
1/5

Significance: muscle weakness d/t to disuse

ANTROPOMETRIC MEASUREMENTS:
Findings:
L
TLL
27.5
ALL
29
Sig.: for baseline data

R
27.5
29

DIFFERENCE
0
0

Postural Assessment
Findings: N/A
Significance: N/A
Functional Analysis:
ADLs
Self-care
Feeding: 1
Grooming: 1
Dressing: 1
Bathing: 1
Toileting: 1
Bed mobility
Roll to right: 3
Roll to left: 1
Supine to sit: 1
Sit to supine: 1
Ambulation: 1
Assessment:

7
6
5
4
3

FIM LEVELS
No Helper
Complete Ind.
Mod Ind.
Min Ind. (subject 100%)
Modified Dep, Min. Asst (75%)
Modified Dep, Mod. Asst (50%)
2 - Complete Dep, Max Asst (25%)
1 - Complete Dep, Total Asst (<25%)

PT Impression:
Problem List
1 Intermittent dull
aching pain on his R
shldr with PS 5/10

LTG ( 12 Tx sessions)
1 To eliminate pain on R
shldr

STG( 6 Tx sessions)
1. To decrease pain on r
shldr

2 Pt. has difficulty in

doing ADL such as
combing hair using
(R) shldr. , bathing,
supine to sit & roll to
(L) & (R).

2 To prevent further
complication such as
contracture

3 Limited ROM on (R)

shldr.
flexion,extension,
abduction, internal &
external rotation
4 (m) weakness on (R)
shldr. flexors,
abductors,internal &
external rotators

To achieve near (N)

ROM on (R) shldr.
flexion, abduction &
external rotation

To achieve optimum
(m) strength on (R)
shldr. flexors,
abductors & external
rotators

5 (+) Postural
deviation

To prevent further
complication such as
scoliosis

Plan:
SUGGESTED Mx:
1.
2.
3.
4.
5.

PROM exercises
Stretching exercise
M straitening on extremities
Joint Mobilization
PBM

To easily do ADLs
such as combing hair
using (R) shldr.,
bathing, supine to sit
& roll to (L) & (R).

To ROM by 5
increments on (r)
shldr. flexion,
abduction & external
rotation
5 To (m) strength by
1 gr. on (R) shldr.
flexors, abductors &
external rotators

5. To achieve (N)
posture