PHYSICAL THERAPY INITIAL EVALUATION

Pt’s name: A.J,P.

Age: 4y/o
Sex: M
Address: Novaliches, QC
Civil Status: N/A
Handedness: Right handed
Occupation: N/A

Religion: Catholic
Nationality: Filipino
Referring Unit: BGH
Referring MD: Dr. E
Rehabilitation Unit: PCMC
Rehabilitation MD: Dr. V
Date of IE: July 10, 2019
Informant/Reliability: Mother
Medical Diagnosis: Cerebral Palsy, hypotonic type with GDD

HISTORY OF PRESENT ILLNESS

This is the case of A.J, 4 y/o male from Qc. Has a twin sister (-) having CP. Twins was delivered
prematurely to a 35 y/o G4 P3 (2-2-0-4) mother on December 1, 2015, via Cesarean deliver and a manner
of breech presentation. ~ 3 yrs PTIE pt.’s mother noticed that her son is having head lag when carrying,
but was able to turn head into right and left when in supine but cannot turn supine to prone by his own;
cannot attend to sit and walk independently. ~ 2 yrs and 9 months PTIE pt’s mother noticed that her son
can hold and recognized his bottle. ~ 2 yrs PTIE pt.’s mother noticed that the pt. can’t still stand alone
despite of his age.~ 1 yr PTIE pt’s mother noticed that the pt. can laugh whenever he is watching
television and knows how to hold mobile phone (unlocked and swipe).~ 9mos ago PTIE pt. can maintain
head in midline, lift head on prone, supine, roll from supine to sidelying, can reach objects, and grasp by
taking with fingers. He can utter single words occasionally & can imitate sound. ~5mos ago PTIE patient
fell on the floor when he was crawling on their bed. ~2mos ago PTIE pt’s mother notice d/t fall his son
scared and cries whenever she puts him into prone. Pt. was initially referred by General Pediatrics due to
motor, language delay. He was last seen on May 16, 2018, assessed with cerebral palsy, hypotonic type
with global developmental delay. He was seen by his neurologist in January 2018. He underwent physical
therapy at PCMC from November 2017 but stopped on March 2018 when no one can accompany him to
his therapy session.
MATERNAL HX
Pt’s mother did not experienced pre-eclampsia during pregnancy denied of having CVD, DM,
HTN; Pt’s mother also denied of smoking & drinking; stated no exposure to toxins & harmful substances.
PRENATAL HX
The pregnancy was unplanned and naturally conceived. The mother became aware ~2 1/2 mo. of
gestation and decided to went hospital to have a medical checkup because of having frequent and severe
hyperacidity; no medications/vitamins taken; obtained a normal weight during pregnancy, was able to
visit her OB-GYN for regular check ups.
PERINATAL HX
A.J, P. is a 4y/o old male pt. was delivered prematurely (AOG: pre-term, 26 wks of gestation) through
cesarean delivery c a manner of breech presentation; labor was ~24; has an APGAR score of 3 initially
then 6 p the next 5 min. was incubated at FEU-NRMF for 1mo. for further observations. A.J,P was
delivered on December 1, 2015.

Criteria 0 1 2
Appearance/ Skin Blue, pale Body pink Completely pink
color
Pulse Absent <100 >100
Grimace/ Reflex No response Grimace Cough, cries
irritability grimace
Activity Limp Some flexion Active motion on all 4’s
Respiration Absent Slow, irregular Good, strong cry

POST NATAL HX
Pt. was admitted to NICU for 1mos d/t being too small, blue colored skin and for further
observations as well.
(-) Trauma to skull

(-) Encephalopathy

(-) Meningitis

ANCILLARY PROCEDURES

Procedure Date Results Location

EEG March 2018 Unknown FEU-NRMF
Findings: unknown
HOME SITUATION:
Pt. stay on his car seat for the whole day and full dependent on his mother for transfer, pt. always
watching television and sometimes his siblings play with him using his favorite toys.
 Pt. lives in a 2 storey house
 Pt. lives with siblings and parents
  Front door ↔ Living room (5 steps)
 Living room ↔ CR (4 steps)
 Living ↔ Kitchen (3 steps)

DEVELPOMENTAL MILESTONES (GROSS MOTOR, FINE

MOTOR,PERSONAL/SOCIAL, SPEECH AND LANGUANGE)

MILESTONES NORMAL AGE OF AGE OF ACHIEVEMENT

ACCOMPLISHMENT

GROSS MOTOR MILESTONES

In prone, turns head side to side Newborn Achieved
Prone to Supine 4 mos. Not yet achieved
Supine to Prone 7 mos. Achieved
Sit with support 6 mos. 1y/o
Sit without support 8 mos. Not yet achieved
Creep 10 mos. Not yet achieved
Crawl 10 mos. Not yet achieved
Cruise 10 mos. Not yet achieved
Arms at high guard 14 mos. Not yet achieved
Arms at low guard walk 18 mos. Not yet achieved
Running 2 y/o Not yet achieved
Jump on B feet 2 y/o Not yet achieved
Walk up and down stairs alone 2 y/o Not yet achieved
Walks up the stairs alternating feet 3 y/o Not yet achieved
Broad jump 3 y/o Not yet achieved
Pedals tricycle 3 y/o Not yet achieved
Walks down the stairs alternating 4 y/o Not yet achieved
feet
Hops on one foot 4 y/o Not yet achieved

FINE MOTOR MILESTONES

Palmar Grasp Newborn Achieved
Crude Grasp 4 mos. 1y/o
Intermediate Grasp 7 mos. 1y/o
Pincer Grasp 10 mos. 1y/o
Piles two cubes 14 mos. 4y/o
Full crayon hold 14 mos. 16 mos.
Scribbles 14 mos. Not yet achieved
Butt-end crayon hold 18 mos. 16 mos.
Raisin drop to bottle 18 mos. Not yet achieved
Hand preference 2 y/o Achieved
Imitates vertical line 2 y/o Not yet achieved
Copies circle 3 y/o Not yet achieved
Copies a cross 4 y/o Not yet achieved
Draws froglike 4 y/o Not yet achieved

PERSONAL/SOCIAL MILESTONES
 Habituation and some control of Newborn 2 mos.
state
Recognizes bottle 4 mos. 5 mos.
Holds bottle 7 mos. 16 mos.
Chews in rotatory movement 10 mos. Not yet achieved
Plays peek-a-boo 10 mos. 3y/o
Finger feeds 10 mos. Not yet achieved
Removes garment 14 mos. Not yet achieved
Puts on garment 18 mos. Not yet achieved
Drinks sweetly from cup 18 mos. Not yet achieved
Toilet training 2 y/o Not yet achieved
Uses spoon well 2 y/o Not yet achieved
Unbuttons 3 y/o Not yet achieved
Dresses and with supervision 4 y/o Not yet achieved

 SPEECH AND LANGUAGE MILESTONES

Cry Newborn Newborn (weak)
State dependent quieting and Newborn 2 mos.
head turning to rattle/voice

Squeals, laughs 4 mos. 5 mos.

Syllable 7 mos. 11 mos.
Syllable 10 mos. 3 y/o
1 word 14 mos. 2 y/o
Points to body part 18 mos. 4 y/o
Learn to say “no” 18 mos. 4 y/o (using head)
Two-word phrases 2 y/o Not yet achieved
Follow simple directions 2 y/o Not yet achieved
Three-word phrases 3 y/o Not yet achieved
Follow prepositional command 3 y/o Occasionally
Questions why, when, how 4 y/o Not yet achieved
Findings: There is a gross motor, fine motor, personal/social and speech language delay.

SUBJECTIVE:
MOTHER C/C
“ Pag inuubo sya sumusuka sya. Tsaka yung head lag nya sana maayos na nya.”
PT TRANSLATION
“ Pt. experience vomiting when coughing, and there is still head lag.”
MOTHER’S GOAL
“ Gusto ko makapag upo na sya magisa at maging maayos yung headlag nya. Kasi yung mga normal na
bata na kaedad nya kaya na. sya hindi.”
PT TRANSLATION
“Pt. can maintain sitting position like the normal child at same age with consistent head control.”
PAST MEDICATIONS

Medicine Dosage Frequency Indication

Cefaclor antibiotic 5ml Od For bacterial infection
Solmux 5ml Od For cough
Findings: meds are used only when symptoms are present
PMHX:
(+) Pneumonia (controlled; started 2017; ended up 2018)
(+) Dental Surgery

PROCEDURE INDICATION DATE HOSPITAL

Dental surgery For dental caries December, 2018 PCMC
Findings: edentulous (upper teeth)
FMHX

Father Mother
HTN (-) (-)
DM (-) (-)
CVD (-) (-)
ALZHEIMER (+) (-)
ARTHRITIS (-) (+)

OBJECTIVE
VITAL SIGNS

VITAL SIGN Normal Value BEFORE DURING AFTER

BP (mmHg) 97-115/57-76mmHg 110/80mmHg 105/70mmHg 105/75mmHg

RR (cpm) 18-25cpm 20cpm 20cpm 19cpm
PR (bpm) 75-118bpm 88bpm 90bpm 94bpm
T° (°C) 36.5-37.2°C 36.7°C 36.3°C 36.6°C
Findings: All VS are WNL
OCULAR INSPECTION (OI)
Mother borne
Alert, easily distracted c toys, uncooperative
Non-ambulatory
Ectomorph
Awake
(+) drooling (Moderate, frequently drools)
(+) Postural deviation (see postural analysis)
(+) head lag
(+) Stranger anxiety
(+) Leg length discrepancy
(+) Separation anxiety
(+) mm atrophy
 (-) dysphagia
(-) hand preference
(-) pes cavus
(-) microcephaly
(-) Swelling on (B) UE/LE
(-) Skin discoloration
(-) Facial asymmetry

PALPATION
Normothermic on all exposed parts of the body
(-) Subluxation/dislocation on (B) extremities.
(-) Edema on (B) extremities
(-) DVT

ANTHROPOMETRIC MEASUREMENT:
Normal: Results
Height: 109cm 51cm
Head Circumference: 45.5 – 51 cm 48cm
Weight: 120lbs 114lbs
Findings: height and weight are below normal, (-) microcephaly
LEG LENGTH DISCREPANCY
R L Difference
TLL 18cm 19cm 1cm
ALL 19cm 19.5cm .5cm
Findings: A discrepancy of 1.5cm is found on LL, with TLL (R) side is shorter than (L) and ALL (L) side
is longer than ®
MUSCLE BULK MEASUREMENT
L R Difference
Biceps brachii 11cm 15cm 4cm
Gastrocnemius 7cm 8cm 1cm
Findings: (+) atrophy or muscle wasting

NEUROLOGIC EVALUATION

SENSORY ASSESSMENT
Tactile Testing

STD: Brush for light touch, thumb pressure for pressure, pin for pain.

Sensation Procedure Findings/Response

Light Touch Pt. felt tingling sensation when
Brush is stroked on Pt.’s (B) LE
he feels the brush
Pain Using the tip of neuro-hammer, Pt. withdraw his LE when he
PT slightly applies pressure on feel pain
 (B) LE
Pressure PT uses thumb and applies Pt. withdraw his LE when he
slight pressure on (B) LE feel the pressure
Visual Testing

Localization PT places a toy 1 ft. away to the Pt. able to follow the toy
(R)
Tracking Toy car was moved from (L) Pt. able to follow the direction
side of the Pt’s face to her (R) of the toy car
side
Threat Do a “peak-a-boo” on the pt. Pt. react when surprise
Auditory Testing

Localization PT call the name of the pt. (R) Pt. able to turn his head towards
side of the Pt’s face the sound
Findings: Normal tactile sensation as to light touch, pain, & pressure; normal visual sensation as to
localization, threat & tracking; normal auditory sensation
A. REFLEXES

1. DTRs/MSRs

++

Legend:
+ + 0 Areflexic
++ + + Hyporeflexic
++ Normoreflexic
++ +
+++ Hyperreflexic
++++ Clonus
+++ +
++ ++

Findings: hyperreflexic on (L) knee

PRIMITIVE REFLEXES
(+) Palmar Grasp
(+) Supporting Reflex
(+) Flexor Withdrawal
(-) ATNR
(-) Moro
(-) STNR
(-) Walking reflex
(-) Equilibrium reflex

PATHOLOGIC REFLEX
(-) Babinski on (B) foot
Findings: plantarflexion and curling of toes
TONE ASSESSMENT:

Legend: Modified Ashworth Scale

0 No ↑in mm tone
1 Slight ↑ in mm tone, manifested by a catch & release or by a min. resist. at the end of ROM when
the affected part is moved in flexion or extension
1 Slight ↑ in mm tone manifested by a catch followed by min. resist. throughout the remainders of
+ ROM
2 More marked ↑ in mm tone through most of the ROM, but affected part easily moved
3 Considered ↑ in mm tone, passive mov’t difficult
4 Affected parts rigid in flexion or extension
Findings: Grade 0 on Both UE & LE considered no increase in muscle tone

ROM: All major joint motions of (B) UE & LE were grossly and passively assessed within pain-free
range and were found WNL, except:
Motion PROM Difference Normal
Shoulder flexion R: 180 R:0 180
L: 170 L: 10
Elbow flexion R: 150 R:0 150
L: 145 L:5
Wrist flexion R:60 R:20 80
L:80 L:0
Wrist extension R:60 R:10 70
L:60 L:10
Hip Flexion c knee R: 90 R:30 120
flexion L: 80 L:40
Knee flexion R: 145 R: 5 150
L: 150 L: 0
Dorsiflexion R: 15 R: 5 20
L:15 L: 5
Findings: LOM of sh. Flexion and elbow flexion, wrist flexion wrist extension and ankle dorsiflexion

FUNCTIONAL MUSCLE TESTING

Activity Grade Description Legend:
FMT
Head control 1 The patient has head lag but 0 = no ability
he has ability to bring back 1 = beginning ability, partially achieved,
unreliable, insecure, momentarily
at midline achieved, inefficient
2 = reliable with abnormal pattern
Trunk control 3 Patient has stable trunk 3 = reliability achieved, efficient,
reliable with good pattern
posture
Rolling Prone 0 Patient could not initiate
→ supine activity with stimulus
placed.
Rolling Supine 0 Patient cannot initiate
→ prone activity
Prone on 0 Patient cannot assume
Elbows position.
Creeping 0 No ability
Quadruped 0 No ability
Crawling 0 No ability
Sitting (assume) 0 No ability
Sitting B/T 0 No ability
Kneeling 0 No ability
(assume)
Kneeling B/T 0 No ability
Half-kneeling 0 No ability
(assume)
Half-kneeling 0 No ability
B/T
Standing assume 0 No ability
Standing B/T 0 No ability

Findings: Pt. cannot perform activities independently.

Significance: Pt. experiences functional limitation due to LOM on (B) LE & UE d/t flaccidity

POSTURAL ANALYSIS: Pt. in sitting position on car seat (A/P/L) with all postural landmarks is
symmetrical & leveled
Body Segment Anterior Lateral
Head Rotated to the L Facing to the L side
Shoulder Aligned Aligned
Elbow Extended Extended
Wrist Extended Extended
Fingers Slightly Flexed Slightly Flexed
Trunk Aligned Aligned
Hips Aligned Aligned
Knee Aligned Aligned
Ankle Slightly plantarflexed Slightly plantarflexed
Findings: patient can bring head towards opposite direction and occasionally hold in midline
SPECIAL TEST
(-) Elys test
Findings: hip of the tested side rises from the table when therapist passively flex the knee.
(-) Phelps Test
Findings: No increase on hip abduction
ASSESSMENT
PT DIAGNOSIS:
Pattern 4C: Impaired Muscle Performance
Pattern 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With
Fracture
Pattern 5C: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of
the Central Nervous System—Congenital Origin or Acquired in Infancy or Childhood
Pattern 5B: Impaired Neuromotor Development
PT IMPRESSION
Pt. was medically dx c Cerebral Palsy, hypotonic type with Global Developmental Delay; wasting, severe
stunting with a strong muscle strength on all limbs. Manifested by no increase in muscle tone on UE,
hyperreflexia on Right LE; persistent primitive reflexes such as Palmar Grasp, flexor withdrawal &
Positive supporting; presence of pathological reflexes such as Babinski sign. 4 years leading to total
assist. on transfers as to bead to car seat, car seat to bed on the axilla & trunk, sit to stand, stand to sit on
the shoulder, & stand pivot on shoulder & trunk. Legs are generally affected more than the arms.
Complete independence on Supine to sit; exhibits gross motor developmental delays as to rolling,
creeping, standing, walking, speech & language. Ancillary procedure such as MRI should be done to have
a clear finding revealing underlying brain abnormalities.
PROGNOSIS
Pt. has a fair prognosis d/t positive supportive reflex and minimal achievement in milestone; some
delayed development of motor milestone and no cognitive deficit. However some positive prognosticating
factors are seen such as there are no 2 complication and may be delayed through rehabilitation; child is
still young and may still develop other milestones; absence of auditory and visual deficits; absence of
seizure and other associated conditions.
PROBLEM LIST:
1. Inability to maintain sitting independently.
2. Unreliable head control.
3. Total dependence on all ADLs.
4. Flaccidity in all limbs
5. Speech and language disorder
6. No increase in muscle tone on both (UE)

LTG: (after 6mos)

1. Pt. will assume sitting indepently.
2. Pt. will lift head in midline consistently, maintain head against gravity and counteract against
gravity independently.
 3. Pt. will be able to use (B) UE and LE limbs independently and be able to hold and grasp objects
firmly.
4. Prevent secondary complications like contracture formation, postural deviations like scoliosis.
5. Pt. will be able to stand c mod assist for ~1min for 3 sets

STG ~ (after 2mos)

1. To improve the consistency of activation of head control
2. To minimize flaccidity on UE & LE.
3. To maintain the integrity of major joint structures.
4. To Stand c mod assist. for ~30 sec. for 3 sets

PLAN
PT MANAGEMENT
1. Rood’s technique
-Quick Stretch: Applied on the distal arm with muscle on a lengthened state
-Light moving touch: Brief light stroking of fingertips (done 3-5x)

2. PROM Exercises: 10 reps x 3 Sets

-Apply on all muscle of UE & LE to prevent development of contractures and maintain ROM

Motor Training: start with rolling

1. Rolling from prone to supine (5reps x3sets)
-Encourage the child to reach the toy as you bring it across her body c your hand on her left hip,
gently bend her hips to 90 degrees and slowly and gently roll her towards her right.
-Move very slowly and allow the child to lead the movement.

2. Half kneeling (~5mins. x3sets)

-Have the child face a table in front of him c toys over it & let him play assuming half kneeling
while PT holds both legs.
3. Creeping (~6 ft ;~5 mins x3sets)
-Prone on elbows c max assist on both arms to increase weight bearing on both UE
-Introduce a toy for creeping activities c total assist to facilitate mobility

2. Upright kneeling Training (5 sec →10 sec→ 15 sec → 20 sec x 3 sets)

-on matress pt. holds the toy on the PT’s hand while PT’s tries to hold it back.

3. UE Reaching activities (5 reps x 2 sets)

-While in POE on firm mat to promote weight bearing on either UE. Place a toy overhead to
promote reaching and will facilitate sh flex, add and ER ( may alternately flex or extend elbow).
-Name parts of the face
 -Weight bearing on one hand, reach for a toy and on hands and knees lift one arm or leg or both

Play Therapy exercises for UE & LE:

-Ball Catching: 5-10 reps x 3 sets
-Bridging: 10 reps x 3sets; hold for 10 sec
-Prone Extension/Superman: 5-10 reps x 3 set
HOME INSTRUCTIONS
1. Maintain the head of the patient at midline to avoid torticollis.
2. Try to find an activity where the patient does in sitting position to maintain sitting position
independently.
3. Educate the parents/ caregiver about proper care, support, and exercises they can do at home with
the patient.
4. Educate the parents/ caregiver about proper nutrition and balance diet of the patient as well as
vitamins to be taken to prevent occurrence of further diseases.
5. Encourage crawling → sitting activities → standing → walking with AD → walking supported
by mother/ care giver s AD → walking independently.
6. Educate the parents/ caregiver or members of the family about proper positioning of the patient.

Referrals:
1. Orthotist – to have pt. prescribed with an orthoses for performance of functional activities, ADLs, and
amb.
2. Occupational Therapist- to help Pt. Address his/ her difficulties in functional activites
3. Nutritionist – to provide the child c appropriate proper balanced nutrition and diet.

Toledo, Jasmine C.

Legaspi, Melvic