LORMA COLLEGES

COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

Carlatan, City of San Fernando La Union
April 12, 2017

This Written Report on

INITIAL EVALUATION
(NEUROMUSCULAR CASES)

Is submitted to the
College of Physical and Respiratory Therapy

In Partial Fulfillment to the requirements

On Subject

Submitted to

Submitted by
Agra, Crissa Julienne E.
Castro, Boun Adrian C.
Picazo, Judy Fe J.
BSPT-IV

LORMA COLLEGES
Initial Evaluation

General Information:

Pts Name : J.N. P

Age : 4 y/o
Sex :M
Address : Brgy. Ili Norte, San Juan, La Union
Civil Status : Single
Citizen : Filipino
Handedness : Right
Religion : Roman Catholic
Date of Consultation : April 14, 2016
Date of Referral : April 21, 2016
Date of IE : April 14, 2017
Diagnosis : CP Spastic Quadriplegia

S:
Informant: Mother
Reliability: Excellent

C/C:

HPI:

Medications:

Name Dosage Indication

quepra bid Anti-convulsant

Ancillary Procedures:
PROCEDURE PLACE DATE IMPRESSION
Cranial CT-Scan ITRMC / March 09, 2012 Possibility of absent
corpus callosum is
considered.
Bilateral parasagittal
fluid collection
separating the lateral
ventricles
Prominent occipital horn
of the left lateral
ventricle
Considered some
CT-Scan LMC October 26, 2012 Cyst of cavum septum
pellucidum and cavum
vergae
Thin CSF containing
clefts extend from the
mid-parietal
subarachnoid spaces to
the borders of both
lateral ventricles
consider bilateral close-
lip schizencephaly
Fronto-temporalparietal
brain atrophy
EEG Bethany hospital January 8, 2013 Presence of burst of high
 amplitude generalized
epileptic form discharges
Generalized slowing of
the background activity
Paucity of sleep pattern
EEG Bethany hospital June 19, 2014 Generalized epileptic
form activity
Poorly defined
asymmetric sleep
pattern

Maternal Hx:
Mothers occupation prior to pregnancy: nurse at Bacnotan District Hospital
Mothers occupation during pregnancy: Company nurse at T.I company
Lifestyle: has an active lifestyle who attended zumba for 4x a month and a non-smoker and a
non- alcoholic beverage drinker
Age of mother upon pregnancy: 26 y/o
Duration of pregnancy: 9 mos
Labor hours: 5-7 hour
(+) ultrasound: 1st mo (@ Dr. Ang Clinic), @ 6 mos of gestation period (@ Bethany Hospital)

Obstetric score (FPAL)

Full term 3

Premature 0

Abortive 1

Living 3

Birth Hx
AOG:
Pt. delivery:
Normal vaginal delivery c cephalic presentation:
Cirmumference:
Birth length:
Birth weight:

APGAR score (unrecalled)

Nutritional Hx:
Pt. was breastfed from birth until 6 mos. old d/t his mother start to work to a private company
and started bottle-feeding from 6 mos up to present.
Pt. started semi solid when he was 8 mos and solid food when he was 1 y/o
Pt. had a good appetite and had no trouble in eating.

Immunizations
Complete Vaccination form BHC( Dates, unrecalled)

Developmental Milestones:
Activities (N) Age achieved Age achieved
Motor skill
Rolling 7 months 3 y/o
Sitting 10 months 3 y/o
Standing 16 months -
Walking 18 months -
Running 2 y/o -
Jumping 2 y/o -
Taking the stairs 3 y/o -
Fine motor
Grasp 9 months 2 y/o
Pen hold 2 y/o 2 y/o
Drawing 3 y/o 4 y/o
Hand dominance 5 y/o 4 y/o
Personal social
Recognizes(familiar) 7 months 3 y/o
Finger feed 10 months -
Grooming 3 y/o
Parallel play 3 y/o
Speech & language
Cry newborn
Laughs, squeaks 4 months
Uses names- dada, mama 10 months 2 y/o
Comprehension 3 y/o

PMHx:
(+) Seizures (petit mal, quepra)
(-) Previous (Other) illness
(-) Surgery
(-) allergy
(-) heart conditions
(-) asthma

FMHx:
Father Mother
DM (+) (+)
HTN (+) (+)
Heart Disease (-) (-)

PSHx:
Pt. have sedentary lifestyle but went to beach near at their house for once in while to practice
walking together with his mom. Pt. spends most of his timw at home c his mother lying in bed or sitting
on w/c. Pt. sometimes plays c colourful alphabet toys and loves watching animated series. Pt. had to go
to school every Monday, Wednesday and Friday at Brgy. Tangqui, San Fernando, La union SPED School.
Pt is living in a bungalow type of house together with his parents and 2 siblings.

Pts Grandmothers goal: Sana hindi na magpatigas ng braso at paa, at sana makatayo na siya ng mag-
sa niya

O:
 OI:
Behavior: cooperative
Level of consciousness: Alert
Manner of arrival: W/c bound
Body built: undernourished
Communication: syllables
(+) esotropia
(+) drooling
(+) head control
(+) cortical thumb on (R) hand
(+) decorticate posture
(+) trunk control
(+) crossed leg
(+) flexible pes planis on B feet
(-) brachycephaly
(-) equinovalgus on feet
(-) pes cavus
(-) flaccidity
(-) attachment
(-) trophic changes
(-) swelling

Palpation
Thermal Assessment: Normothermic on all exposed areas
Tone Assessment: Hypertonic on (B) UE & LE
(-) Dislocations
(-) Subluxations
(-)Tightness
(-) tenderness

Neurological Exam
Sensory Assessment: N/A d/t inability to communicate
Auditory Assessment
Device Used: keys
Findings: Pt does not react nor gaze on any stimulus given
Sig: 2 to affectation on BA 41, 42
Visual Assessment:
Visual tracking:
VTD Used: keys
Localization: 1 foot away from the pt, laterally moved from (R) to (L) and upwards
moving downwards
Findings: Pt wasnt able to follow the key through her eye from (R) to (L) and upwards
and downwards
Sig: 2 to affectation of BA 18, 19

Visual threat:
VTD Used: keys
Localization: 1 foot away from the pt, sudden drop of keys over the pt.s face.
Findings: Pt didnt blink nor attempt to protect herself from stimulus.
Sig: 2 to affectation of BA 18, 19
 DTR:
(R) (L)

N/A N/A

Legend:
N/A N/A 0 areflexia
N/A N/A + hyporeflexia
++ normoreflexia
+++ hyperreflexia
+++ +++ ++++ clonus

+++ +++

Note: UE was not assessed 2 to pts inability to relax

Findings: Hypereflexive on (B) LE
Significance: 20 affectation of UMNL

Pathologic reflexes
Findings:
(-) Babinski
(-) Chaddocks
(-) Gordons
(-) Clonus
Significance: For baseline data

Primitive reflexes
Findings:
(-) Palmar Grasp
(-) Plantar Grasp
(-) ATNR
(-) STNR
(-) Moro
(-) Foot placement

Significance: for baseline data

Tone assessment
Legend

0- No response
1- Decrease response
2- Normal response
3- Exaggerated response
4- Sustained response

Findings: Pt has grade 3 muscle tone on (L) UE & LE and grade 4 muscle tone on (R) UE & LE.
Significance: 20 injury to pyramidal tracts of the brain

Spasticity assessment (Modified Ashworth scales)

Legend :
 Modified Ashworths Scale
0 No increase in muscle tone
1 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
2 Marked increase in muscle tone through most of ROM, but affected parts easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected parts rigid in both flexion and extension

Findings: Grade 3 flexor spasticity on (B) UE & LE

Significance: 20 injury to pyramidal tracts of the brain

ROM:
Findings: All motions of (B) UE and and LE, neck and trunk are WNL passively pain-free c N end feel
except:

Motion Right Left NROM DIFFERENCE END FEEL

PROM PROM RIGHT LEFT
elbow flexion 0-120 o 0-120 o 0-150 o
elbow 120-0o 120-0o 150-0 o
extension
hip c knee 0 65o 0 60o
flexion
hip abduction 0-35 o 0-40 o 0-45 o
knee 130-0 o 130-0 o 135-0 o
extension
Knee flexion 0-130 o 0-130 o 0-135 o
ankle 0-20 o 0-20 o 0-20 o
dorsiflexion
plantar flexion 0-50 o 0-50 o 0-50 o

Special Tests
PROCEDURE POSITIVE SIGN Significance
(+) Thomas test It is done by bringing
both legs up to the
chest to stabilize the
lumbar spine.
One leg at a time is
extended until there
is resistance in hip
extension or
movement in the
pelvis
(+) Elys test Prone with the if the buttock rises spastic or tight
examiners hand in off the table quadriceps
the buttock
The lower leg is
quickly flexed..
Functional Analysis:

ADL GRADE
Self care
Feeding 1
Grooming 1
Bathing 1
Upper Garment 1
Dressing
Lower Garment 1
Dressing
Sphincter Control
Bladder Mx 1
Bowel Mx 1
Mobility
Bed mobility
Chair mobility 1
1
Toileting
1
Transfer
1
Locomotion
Gait
1
Expression
1
Communication
Comprehension 1
Expression 1
Social Cognition
Social Interaction 1
Memory 1
Problem Solving 1

Sig: Pt. needs total assistance in performing ADLs

Reach/Grasp/Release:

(R) (L)
Reach (+) (+)
Grasp (+) (+)
Release (+) (+)

Findings: Good RGR

Sig.: 2o to strong finger flexors & extensors

PA: N/A

GA: N/A
A: