IPT December 08, 2011 Patient’s Name: Mayhew, George Age: 47 y/o Sex: Male Dx: CP Quadriplegia S: Px goes to rehab for strengthening

of (B) UE/LE and body conditioning exercise O: VS: Bp: a: 110/70 mmhg P: 110/80mmhg Pr: a: 76 p: 80 Rr: a 24 p: 28 Temp: afebrile to touch OI: W/c bound Alert, coherent, cooperative  Endomorph (+) Atrophy on (B) UE/LE (+) Scar on head (+) Deformity (clubfoot ®)   Palpation:  Normothermic on all exposed body parts  (+) flexion contracture on (B) knees Grade 1 spasticity on (B) UE/LE  (-) Mm spasm (-) Mm tenderness (-)edema Behaviour (+) Response to activities (+) Eye contact (+) Follow command (+) Attention span NE tone ass: Hypertonic on (B) UE/LE Neuro Eval. Sensory Testing STD Used: Pin-Pain Cotton-Light touch Thumb- Pressure Findings: 100 % intact sensation on (B) UE/LE as for pain, light touch and pressure Sig.: Intact BA 3, 1, 2 DTR:

Areflexia IHyporeflexia IINormorelexia IIIHyperreflexia IVClonus Findings: Hyperrelexia on (B) UE and ® LE * note: ® foot was not assessed due to clubfoot defority Sig. Mm tightness and deformity FMT Hand to mouth Hand to back head Hand to opposite shoulder Raise up Pronate/supinate Grasp Pinch LE Heel to opposite knee Flex hip and knee flex Abduct legs (L) 3 3 3 4 3 3 3 2 3 3 ® 3 3 3 4 3 4 3 2 3 3 Grade 4: Reliably achieved and efficient Grade 3 reliably achieved but in abnormal motion Grade 2: Task partially done Grade 1: No ability Finding: Mm weakness on (B) UE/LE Sig: secondary to deconditioning FIM Self care Transfer .: secondary to hypersensitivity of reflex arc ROM: All tested joints of (B) UE are WNL actively and passively done pain free except for (B) (N) (A) (P) AD PD EF Shoulder Flexion 0-180 0-150 0-160 30 20 Firm ® knee ext (L) knee ext ® ankle DF PF 135-0 135-0 0-20 0-50 135-30 135-30 0-10 0-20 135-45 135-45 0-20 0-30 100 100 10 30 100 100 0 20 Firm Frm Firm Firm Finding: LOM on (B) shoulder flexion. (B) knee extension.Legend: 0. ® ankle dorsiflexors and plantar flexion Sig: LOM secondary to Mm contracture.

LOM on (B) shoulder flexion. ® ankle dorsiflexors and plantar flexion 2. Spasticity on (B) UE/LE 4.Minimum assist 3-Moderate assist 2-Maximim assist 1-total assist Finding: Dependency on self-care. Sitting push-up X 7sh X 10reps X 1set . ® ankle dorsiflexors and plantar flexion 2. Atrophy of (B) UE/LE 3. (B) knee extension. Hypereflexive on (B) UE/LE 7. Flexion contracture on (B) knees 5. (B) knee extension. transfer and locomotion Goals 1. To prevent any further atrophy of (B) UE/LE 3.PRE X 15 reps X 1set on (B) UE/LE c 5 lbs DB and LAW(AP) 2. toileting. To prevent further flexion contracture on (B) knees 5. To achieve highest possible ROM on LOM on (B) shoulder flexion. toileting. Dependency on self-care. Prevent any further spasticity on (B) UE/LE 4. During and after the PT session Problem list: 1. transfer and locomotion Sig: secondary to CP Quadriplegia A: PT Impression: Px is fully independent in almost all ADL secondary to spastic quadriplegia Patient reaction to treatment:  Patient was cooperative and was able to tolerate all PT management s any adverse effects. To retard deformity on ® clubfoot P: PT Management: 1.Eating:2 Bathing:2 Grooming:2 Dressing UE: 2 LE: 2 Toileting:1 Sphincter CTRL Bladder Mgt: 3 Bowel Mgt:3 Social Cognition Social interaction: 7 Problem Solving: 5 Memory:7 Bed to chair:7 Toilet:1 Tub:1 Locomotion Walk: 1 Stairs:1 Communication Comprehension: 6 Expression: 6 Grading 7. Pelvic bridging X 10 sh X 10 reps X 1set 4. Deformity on ® clubfoot 6. Stretching exercise X 15shX 10 reps X 1set on (L) ankle DF 3.Complete independence 6-Modified independence 5-Supervision 4.

Approve By: Vilma A Ramos. Lacson PT Intern ‘12 . PTRP Chief PT Prepared By: Christian G.