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Pediatric assessment form

Name : chronological age :2years sex : F session #:3 functional age: 6-8months

history of present illness :


what bring your child to therapy today? Cere ra! "a!sy # hy"oton$a when did it start? From a%e &8 months ' ( the mother sa$) that ma!a* +as norma! ,nt$! a%e 8 months ( an) she )oes not remem er any th$n% that !ea) to the C- hy"oton$a . Did your child take other physiotherapy session ? no Effects of treatment and progress over time? /t0s the th$r) treatment sess$on 1or ma!a* . / +or*e) +$th ma!a* the 1$rst sess$on an) the th$r) sess$on . she "o%resses $n a %oo) manner : 2' 3he s$tt$n% a!an4e no+ $s etter . no+ she 4an s$t $n)e"en)ent!y +$th !o+ r$s* o1 1a!! 1or 2 m$n . & 1$rst sess$on : on!y 1or 35-65 se4 $n)e"en)ent!y +$th mo)erate r$s* o1 1a!! ' . 2' 7oro re1!e8 $n the 1$rst sess$on +as "os$t$9e ( $n the th$r) sess$on $s ne%at$9e . Did your children have pain ? 0 2 2 3 6 : 6 ; 8 < 25. an you describe the type of pain ? =he )oes not ha9e "a$n urrent medications: =he )oes not ,se any me)$4at$ons

Past medical history : &s,r%er$es( other':


C!ear

Family and social history:


who is your child caregiver ? mother number of child same condition in family : 5 . son order : 3 genetic diseases : no %enet$4 )$seases fre!uency of same case in the family: on!y ma!a* "moking in house: no #ob situations: the 1ather $s se!!er ( mother )oes not +or* . $ny agnation between parents ? no

Perinatal history:
mother age : 36 maternal fever or rash : no

maternal diabetes : no drug that taken during pregnancy : no exposure to radiation : no duration of pregnancy %normal &'weeks( : < month any complications during pregnancy: no neonatal )aundice : no mode of delivery : norma! )e!$9ery any complications during delivery : no .

Motor milestone :
>orma!? atypical *delayed $1 aty"$4a! or )e!aye) ( !$st yo,r 4h$!) a%e at the t$me o1 )emonstrat$on 1or the 1o!!o+$n% : rolling over: 6 sitting up: 2years crawling: ,nt$! no+ she )oes not 4ra+! cruising : 2 year first words : a year walking: she )oes not +a!* eating with spoon + fork : no

Examination : Medical examination :


3y"e /nte!!e4t,a! A"$!e"t$4 se$C,re D$s$on Eear$n% Fromotor Hes"$ratory "ro !ems >orma! B B B B B G$11$4,!t$es $n mo,th 4!os,re. Cont$n,o,s sa!$9at$on . @ )om$na! m,s4!es +ea* .. =tra $sm,s ( &+$th eye %!asses ' @ norma! B A8"!anat$on

Motor examination :
1.Tone : ,ypotonic 2.Muscle bulk : norma! 3. eflexes : a! "T : a!! the )ee" ten)on re1!e8es are )$m$n$she) . 'superficial reflexes : a )om$na! re1!e8 $s a sent c!patholo#ical reflex: "!antar re1!e8 & a $ns*$ re1!e8 ': a sent .& !o+er motor ne,ron s$%n ' )' Primiti$e reflexes : $"-N. : ne%at$9e .

"-N. : ne%at$9e &+h$4h $s a %oo) s$%n ( e4a,se th$s s$%n $s +hen $ts )$m$n$she) ( $t $ntro),4e the a y to 4ra+! ' /0.0 : ne%at$9e & note: $n sess$on n,m er 2 ( the moro re1!e8 +as "os$t$9e ( ,t $n sess$on 3 ( $ts a sent' ( +h$4h a s$%n o1 "ro%nos$s a!so . "-E112N3 : ne%at$9e 4$56.2N-,: ne%at$9e

e!Postural reactions :
Neck detoriorational reflex : ne%at$9e . 4andu reflex :ne%at$9e . 1arachute reflex: "os$t$9e & s,$ta !e at 6-< months ( +h$4h $s the 4orre4te) a%e 1or the a y'. 1ull to sit : hea) !a) & at a%e 3-6 months ( +e sho,!) ha9e a4t$9e 1!e8$on o1 ne4*' I,t $n th$s 4ase +e ha9e "oor hea) 4ontro! .

%.MMT :
@!! the m,s4!es o1 the ,""er e8trem$ty are 1,n4t$ona! . 3he m,s4!es o1 the !o+er e8trem$ty are +ea* 1,n4t$ona! .

Physical examination:
1!&ack assessment : =4o!$os$s 2!Pel$ic obli'uity : -e!9$4 $s $no !$J,e 3!(ip assessment : -homas test : ne%at$9e & no shorten$n% $n h$" 1!e8ors ' $dduction contractures test : ne%at$9e Ely7s test : ne%at$9e ,ip rotation: & "os$t$9e ' ( e84ess$9e e8terna! rotat$on %!)nee assessment : 1atella position: norma! 1osterior capsule tightness : ne%at$9e . *!foot and ankle assessment : a'@n*!e : Kastro4nem$,s 4ontra4t,res &s$!9ers*o$) test' : ne%at$9e 'Foot : normal ? "es 9a!%,s ? -es 9ar,s ?

Ea!!,8 9a!%,s

+!,MF-. :
/e$el accordin# to #ross motor function classification scale 0,MF-.! : 2: +a!*s +$tho,t restr$4t$ons 2: +a!*s +$tho,t ass$st$9e )e9$4es ,t !$m$tat$on $n 4omm,n$ty 3: +a!*s +$th ass$st$9e )e9$4es 8:transported or uses powered mobility :: se9ere!y !$m$te) )e"en)ent on +hee!4ha$r

Milestone examination : Can .olling : Ho!! 1rom "rone to s,"$ne Ho!! 1rom s,"$ne to "rone "itting : From s,"$ne Fn 1!oor From stan) rawling "tanding .ensory examination 4ight touch 9 pinprick : $m"a$re) 1roprioception ( $s $m"a$re) . "uperficial sensation & e.%. : stereo %enes$s ': / 4annot )eterm$ne +hether $ts $nta4t or $m"a$re) ( e4a,se the %$r! $s not norma! 4o%n$t$9e!y . &alance examination : / e8am$ne) the a!an4e ),r$n% s$tt$n% ( the a y !ean to 1a!! +hen he $s s$tt$n% 1or more than 2 m$n,tes $n)e"en)ent!y . 5races and assistive devices : >o . 0ther investigation : 2' 2' 3' 6' Dery "oor tr,n* sta $!$ty an) 4ontro! . Lo$nt hy"ermo $!$ty( so ran%e o1 mot$on $n a!! Lo$nt $s more than norma!. Fro% "os$t$on . M- "os$t$on +h$!e s$tt$n% & more ase o1 s,""ort ( more a!an4e ' . B B B B B =$tt$n% +$th +$)e ase o1 s,""ort ( +$th ro,n)e) s"$ne & +- "os$t$on ' B 4annot A8"!anat$on =!o+ mot$on

*! Plane of care:
Problem list : 2. hy"oton$a 2. @%a$nst %ra9$ty a4t$9$t$es are +ea* 3. s!o+ mot$on $n a!! a4t$9$t$es . 6. Me$%ht ear$n% on !o+er e8trem$ty $s +ea* :. -ost,ra! $nsta $!$ty ( &hea) an) tr,n* 4ontro! are "oor ' 6. Hemar*a !e )e4rease $n the !e9e! o1 aro,sa!. .hort term #oals : 2. %oo) a!an4e +h$!e s$tt$n% &6 +ee*s' 2. to stren%th a!! the m,s4!es ( es"e4$a!!y "e!9$4 an) a )om$na! m,s4!es ( $n or)er to start +$th 4ra+!$n% . & 3 +ee*s-6+ee*s' 3. "ro%ress$9e!y $n4rease sensory $n",t&6 +ee*s' . 6. $n4rease tone &6 +ee*s' :. enhan4ement o1 hea) an) tr,n* 4ontro! & 6 +ee*s' 6. to +or* on )ee" sensat$ons & e.%: o,n4$n% on a !ar%e a!!' /on# term #oals: 2. %oo) hea) an) tr,n* 4ontro! &3months' 2. to try to norma!$Ce the tone &2 year ' 3. 4ra+!$n%&6 months ' 6. stan)$n% &2.: year' :. to ha9e near norma! sensory an) )ee" sensat$ons . & 2 years' -reatment plan and 1rocedural intervention: 2. a4t$9e mo9ements a%a$nst %ra9$ty 2. st$m,!at$on 1or hea) an) tr,n* ra$s$n% & ,s$n% ro!! ' 3. to $n4rease the aro,sa! !e9e! ( ,s$n% "ro%ress$9e sensory $n",t . & e.% : o,n4$n% on a!! ( ,s$n% s"e4$a! 9o$4es ( at +h$4h the 4h$!) sho+s res"onses to ' . 6. to +or* on m$)ran%es & e4a,se these 4h$!)ren ha9e Lo$nt hy"ermo $!$ty ( +h$4h !ea) to e84ess$9e ran%es' . :. "ro%ress$9e sensory $n",t 6. +e$%ht ear$n% on han)s ,s$n% the =+$ss a!!. ;. st$m,!ate them to 4ra+! . & ,s$n% a ,$!t ( aro,n) the +a$st ( an) ma*e mo9ements ( that m$m$4 the 4ra+!$n% ' .

8. e8er4$ses 1or anter$or "e!9$4 t$!t an) "oster$or "e!9$4 t$!t a!so ,s$n% =+$ss a!! . <. ),r$n% a!! these e8er4$ses ( a 9o$4e that st$m,!ate the %$r! $s t,rne) on N 25. o,n4$n% on a =+$ss a!!.

-herapist name: /aisa $hmad "leman Date of examination: &:+:0+;0:&