Name: Balingit, Franz Angelo

Age: 6 y/o

CRS PEDIATRIC CLINIC 2016

Diagnosis: Cerebral Palsy Spastic Diplegia
Clinic: MOC

PT NOTES
GOAL FOR TODAY: To ambulate around MOC hallway for 3x with manual
contact on (B) Hands
June 8, 2016
S> No New complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP
HR (bpm)
91
105
RR (cpm)
41
25
Temp
37.1
36.5
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative
> - Pt. is not in apparent pain and respiratory Distress
> - (+) Left beating nystagmus
PT MANAGEMENT GIVEN:
1. Sustained Stretching on (B) Hip and Knee flexors and ankle plantar flexors
x 2.5 minutes x 3 reps x 1 set, OD
2. Sit to stand activity with AFO on green monoblock chair x 10 reps x 1 set,
OD
3. Standing tolerance with postural reinforcements x 5 mins x 1 set, OD
4. Ambulation with AFO around MOC hallway with manual contact on (B)
Hands x As tolerated
5. Trunk control on vestibular ball x 5 minutes x 1 set, OD
6. Crawling activity with RI x As tolerated
REACTION TO TREATMENT:
Pt. was not able to perform all exercises due to excessive tightness of (L) Hip
flexors, Knee Flexors and ankle plantarflexors. Pt. cried during stretching
exercises due to pain. Pt. have not shown any Adverse effect.
A> Goal for today was not achieved . Pt. was only given stretching exercises.
P> Continue same management next session. Goal for next session is to
focus on stretching (B) Hip and knee flexors and Ankle Plantarflexors up to
neutral
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
GOAL FOR TODAY: to tolerate standing with PKS on (B) Knees with support on
Pelvis for 10 mins
June 15, 2016
S> No new complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
After
BP
80/70
80/70
HR (bpm)
88
95
RR (cpm)
28
32
Temp
36.7
35.5
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative

>
>

- Pt. is not in apparent pain and respiratory Distress

- (+) Left beating nystagmus

PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
Pulsed US on Plantarflexors x 1.0 watts/cm 2 x 8 minutes, OD
Stretching of (B) LE on AP x 30 seconds hold x 3 reps x 1 set, OD
Sit to stand exercise using a green monoblock x 10 reps x 1 set, OD
Standing balance and tolerance with PKS on (B) Knees x 5 minutes x 1 set,
OD

REACTION TO TREATMENT:
Not all management was given to the patient. The focus of the management
this session is on Standing balance and tolerance. Pt. cried during the whole
treatment starting from the application of the US gel up to Standing Balance
and tolerance specially on the application of the PKS on (B) Knees.
A> Goal for today was not achieved . Pt. was able to tolerate standing
balance and tolerance with PKS on (B) knees for 5 minutes even though
the patient cried a lot during the tx.
P> Continue same management next session. Goal for next session is for Pt.
to ambulate around MOC hallway for 5 rounds with manual contact on (B)
Hands.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
contact on (B)
June 17, 2016

GOAL FOR TODAY: To ambulate around MOC hallway for 5 rounds with manual
Hands without splint
S> No new complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
BP
80/70
HR (bpm)
94
RR (cpm)
20
Temp
35.8
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative
> - Pt. is not in apparent pain and respiratory Distress
> - (+) Left beating nystagmus

After
80/70
105
25
36.4

PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
Pulsed US on Plantarflexors x 1.0 watts/cm 2 x 8 minutes, OD
Stretching of (B) LE on AP x 30 seconds hold x 3 reps x 1 set, OD
Sit to stand exercise using a green monoblock x 10 reps x 1 set, OD
Standing balance and tolerance with PKS on (B) Knees x 6 minutes x 1 set,
OD
5. Ambulation around MOC hallway with manual contact on (B) hands
without Splint x 5 rounds x 1 set, OD
REACTION TO TREATMENT:
Pt. was given all the tx without any Adverse effect. Pt. was able to tolerate
standing balance and tolerance with PKS on (B) knees for 6 minutes. Pt. was
able to complete 5 rounds of ambulation around MOC hallway without his AFO

but with manual contact on (B) Hands. Pt. Still cried during Ultrasound
application, Stretching and standing balance tolerance but only 50% of the
time.
A> Goal for today was achieved . Pt. was able to ambulate around MOC
hallway for 5 rounds with manual contact on (B) Hands
P> Continue same management next session. Goal for next session the
same.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
contact on (B)
June 20, 2016

GOAL FOR TODAY: To ambulate around MOC hallway for 5 rounds with manual
Hands without Splint
S> No new complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
BP
80/70
HR (bpm)
96
RR (cpm)
35
Temp
35.7
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative
> - Pt. is not in apparent pain and respiratory Distress
> - (+) Left beating nystagmus

After
80/70
90
35
35.4

PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
Pulsed US on Plantarflexors x 1.0 watts/cm 2 x 8 minutes, OD
Stretching of (B) LE on AP x 30 seconds hold x 3 reps x 1 set, OD
Sit to stand exercise using a green monoblock x 10 reps x 1 set, OD
Standing balance and tolerance with PKS on (B) Knees x 6 minutes x 1 set,
OD
5. Ambulation around MOC hallway with manual contact on (B) hands
without Splint x 5 rounds x 1 set, OD
REACTION TO TREATMENT:
Pt. was given all the tx without any Adverse effect. Pt. was able to tolerate
standing balance and tolerance with PKS on (B) knees for 6 minutes. Pt. was
able to complete 5 rounds of ambulation around MOC hallway without his AFO
but with manual contact on (B) Hands. Pt. Still cried during Ultrasound
application, Stretching and standing balance tolerance but only 25% of the
time.
A> Goal for today was achieved . Pt. was able to ambulate around MOC
hallway for 5 rounds with manual contact on (B) Hands
P> Continue same management next session. Goal for next session is the
same and use pt. AFO for the ankle if available.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
contact on (B)

GOAL FOR TODAY: To ambulate around MOC hallway for 5 rounds with manual
Hands with without Splint

June 22, 2016

S> No new complaints

O> (See Vs Chart) All WNL
Vital Signs
Before
BP
80/60
HR (bpm)
95
RR (cpm)
29
Temp
36.2
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative
> - Pt. is not in apparent pain and respiratory Distress
> - (+) Left beating nystagmus

After
80/70
100
32
36.2

PT
1.
2.
3.
4.

MANAGEMENT GIVEN:
Pulsed US on Plantarflexors x 1.0 watts/cm 2 x 8 minutes, OD
Stretching of (B) LE on AP x 30 seconds hold x 3 reps x 1 set, OD
Sit to stand exercise using a green monoblock x 10 reps x 1 set, OD
Standing balance and tolerance with PKS on (B) Knees x 6 minutes x 1 set,
OD
5. Ambulation around MOC hallway with manual contact on (B) hands
without Splint x 5 rounds x 1 set, OD
REACTION TO TREATMENT:
Pt. was able to tolerate all given management without any adverse effect. Pt.
cried during US application and stretching as well as standing balance and
tolerance all throughout the treatment but somehow stopped when he heard
the noise of the timer. Pt. ambulated around MOC hallway with manual
contact on (B) Hands (25%) and tolerated it without his AFO.
A> Goal for today was achieved . Pt. was able to ambulate around MOC
hallway for 5 rounds with manual contact on (B) Hands
P> Continue same management next session. Goal for next session is the
same and use pt. AFO for the ankle.
Herradura, Phyllis Yna G.
DLSHSI PT Intern
PT NOTES
contact on (B)
June 24, 2016

GOAL FOR TODAY: To ambulate around MOC hallway for 5 rounds with manual
Hands with without Splint
S> No new complaints
O> (See Vs Chart) All WNL
Vital Signs
Before
BP
80/70
HR (bpm)
91
RR (cpm)
41
Temp
37.1
>
> OI:
> - Bedbound
> - Ectomorph
> - Alert, Coherent, and cooperative
> - Pt. is not in apparent pain and respiratory Distress
> - (+) Left beating nystagmus

After
80/70
108
25
36.5

PT
6.
7.
8.
9.

MANAGEMENT GIVEN:
Pulsed US on Plantarflexors x 1.0 watts/cm 2 x 8 minutes, OD
Stretching of (B) LE on AP x 30 seconds hold x 3 reps x 1 set, OD
Sit to stand exercise using a green monoblock x 10 reps x 1 set, OD
Standing balance and tolerance with PKS on (B) Knees x 6 minutes x 1 set,
OD
10.Ambulation around MOC hallway with manual contact on (B) hands
without Splint x 5 rounds x 1 set, OD
REACTION TO TREATMENT:
Pt. was able to tolerate all given management without any adverse effect. Pt.
cried for 1 minute during US application but stopped for the rest of the tx. He
tolerated stretching without crying but cried during PKS application on
standing balance tolerance for 10 minutes. Pt. ambulated around MOC
hallway and tolerated it for 5 rounds with (25%) manual contact on (B) hands.
Pt.s AFO cannot be used because it cannot be fitted to him anymore.
B> Goal for today was achieved . Pt. was able to ambulate around MOC
hallway for 5 rounds with manual contact on (B) Hands
P> Continue same management next session. Goal for next session is the
same and use pt. AFO for the ankle and provide less manual contact by
holding on to one hand only during ambulation.
Herradura, Phyllis Yna G.
DLSHSI PT Intern