PEDIACTRIC INITIAL EVALUATION

General Information
Kid’s Name : A.C
Birthdate : August 7, 2016
Addresses : Mandaluyong City
Age : 2 y/o
Sex : Female
Handedness : Right
Referring Dr : Dr. A.B
Referring Unit: Our Lady of Lourdes Hospital (Nuero-ward/OPD)
Rehab Dr : Dr. C.C
Date of consultation: July 17, 2017
Date of Referral: July 18, 2017
Date of IE : July 19, 2017
Diagnosis : Cerebral Palsy Diplegia
Treatment Schedules :

SUBJECTIVE
Informant : Mother
C/o : “nahihirapan po sya tumayo mag-isa at hindi nya kayang maglakad.
Informant’s Goals: Mother wants her daughter to stand and walk independently and
safely in order to perform child’s ADL’s such as playing outside.
Informant’s Attitude : Good

History of Present Illness (HPI)

Maternal History:
Pt’s mother is a 25 y/o teacher. Pt’s mother is non-cigarette smoker and drinks
alcoholic beverages occasionally (~ 3 bottles per occasion). Had no any secondary
complications such as HTN, DM, cardiopulmonary disease and negative trauma and
hospitalization. Pt’s mother prefers to eat meat and vegetables, love to cook and go
shopping. Goes to gym every weekends for 2 hrs.

Prenatal History:
Mother conceived A.C at 25 years of age. Mother didn’t notice that she is
already pregnant that time. She didn’t go to clinic for check- up in the first
trimester of her pregnancy.

Perinatal History:
 Premature Birth
 NSD p 18 hours labor
 Cephalic presentation
 Birth weight 2kg
Post Natal History:
 The Pt. undergone newborn screening & mother reported that the findings are
Normal.

APGAR Scoring
- After 1 minute
- After 5 minutes
0 1 2
Appearance Blue Body: pink Pink
Limbs: blue
Pulse Absent <100bpm >100bpm
Grimace No reaction Grimace to slight Cries
Facial twitching
Activity No movement Slight flexion Spontaneous
Respiration No chest expansion Slight cries
Legend:
0-4 – needing ventilator support
5- 6 – impending respiratory arrest; needs close monitoring
7-10 – good prognosis
Findings: Apgar score 7

Developmental Milestones:

MOTOR MILESTONE AGE ACHIEVED

4MONTHS
- Waves arm at sight of toy held in air Achieved

- Lap baby Achieved

6months
- head steady in sitting
Achieved
- crude palmar grasp 6months

- turns prone to supine 6months

Achieved
- symmetric posture Achieved

- laughs
- recognize bottle in sight
5- 6MONTHS
- Grasp rattle or objects 8months
- Bears weight on legs
- No head lag pull to sit
- Rolls over 10months
- Sit with support
 - Reaches for objects 1year

7MONTHS
- One hand reaching 9months
- Rolls to supine to prone
- Bears weight & bounces if held
standing
- Hold bottle in feeding
- Talks to mirror image
- Looks down on dropped objects
- Stranger anxiety
8-9 MONTHS
- Feeds self with cracker 1year
- Sits without support NA
- Imitates speech sounds NA
- Forward parachute NA
10 MONTHS
- Crawls 2years
- Pulls self to standing 3year

11- 13MONTHS
- Play patty cakes NA
- Plays ball
- Indicates want
- Stoops & recovers
14- 18MONTHS
- Towers 3 cubes NA
- Turns pages of books
- Identifies pictures
- Walks
19- 24MONTHS
- Uses spoon 5years
- Pulls on garment NA
- Toilet training begins NA
- Walks ups & down stairs NA
- Begins to run NA
Note: NA- Not Achieved

Ancillary Procedure
Diagnostic Procedure Date Findings
MRI Scan January 2017 (+) periventricular
leukomalacia
(+) polymicrogyria
New born screening August 2016 Normal
Present medication
Medication Dosage Frequency Indication
Dantrolene Starts with 0.5mg/kg 5–7 days Drug of choice for
bid; increase by 0.5 spasticity of
mg/kg ; max: cerebral
12 mg/kg/d to 400 origin
mg
Clonidine Start with 0.1mg patch for 7 days For reducing
muscle spasm

Vaccinations
Name Dose Date
BCG 2 mos October 10, 2016
DPT1 2 mos October 10, 2016
OPV1 3 mos November 10, 2016
OPV2 4 mos December 10, 2016
Hepa B1 5 mos January 10, 2017
Hepa B2 9 mos May 10, 2017

Past Medical History (PMHX)

 (-) Hospitalization

Family Medical Hixtory (FMHx)

Maternal Paternal
Rubella (+) (-)
Mumps (-) (+)
Epilepsy (-) (-)
Pulmonary Disease (-) (-)
Personal/Social/Environmental History (PSEHx)
 2st child
 Mother is the primary care giver at home
 No previous therapy reported
 Px plays more often in the living room

OBJECTIVES:

Informant’s Complaints:
“nahihirapan po sya tumayo mag-isa at hindi nya kayang maglakad.

Informant’s Goals: Mother wants her daughter to stand and walk independently and
safely in order to perform child’s ADL’s such as playing outside.
Vital Signs:
A During P
Pulse rate 120bpm 120bpm 115bpm
Respiratory rate 12cpm 12cpm 15cpm
Temperature 36.7 °C 36.7 °C 37.2 °C
Significance: For frequent monitoring of VS and Tx precautions; possible difficulty in
breathing

OI
 Ectomorph
 Alert, coherent, uncooperative
 Sometimes cry
 Microcephalic
 (+) drooling of saliva
 (+) Strabismus (convergent)
 (+) Postural deviation (see postural analysis)
 (+) Gait abnormality (see gait analysis
 (-) Attachment

Palpation:
 Normothermic on all exposed body parts.
 Normal skin turgor, mobility and consistency
 (-) Subluxation
 (-) Taut band

NEUROLOGICAL EVALUATION
I. Tone Assessment
Legend
1- Hypotonic
2- Normotonic
3- Hypertonic

Findings:
Significance:

Ashworth Spasticity Scale

0- no increase in muscle tone
1- slightly increase in muscle tone manifested by a catch or release at the beginning
or end of ROM
1+ - slightly increase in muscle tone manifested by a catch or release less than of
the ROM
2- slightly increase in muscle tone manifested by a catch or release more than half
of the ROM
3- passive ROM is difficult
4- rigidity
 5- MUSCLE ® (L)
GROUP
Shoulder flexors 1+ 1+
Shoulder extensors 1+ 1+
Shoulder abductors 1+ 1+
Shoulder adductors 1+ 1+
Shoulder IR’ors 1+ 1+
Shoulder ER’ors 1+ 1+
Elbow flexors 1+ 1+
Elbow extensors 1+ 1+
FA pronators 1+ 1+
FA Supinator’s 1+ 1+
Wrist Flexors 1+ 1+
Wrist Extensors 1+ 1+
Wrist Ulnar deviators 1+ 1+
Wrist Radial deviators 1+ 1+
Fingers extensors 1+ 1+
Fingers flexors 1+ 1+
Fingers abductors 1+ 1+
Fingers adductors 1+ 1+
Hip flexors 1+ 1+
Hip extensors 1+ 1+
Hip abductors 1+ 1+
Hip adductors 1+ 1+
Hip IR’ors 1+ 1+
Hip ER’ors 1+ 1+
Knee flexors 1+ 1+
Knee extensors 1+ 1+
Ankle plantarflexors 1+ 1+
Ankle Dorsiflexors 1+ 1+
Ankle Evertors 1+ 1+
Ankle invertors 1+ 1+
Findings: Generalized Hypotonicity on (B) UE/LE.
Significance: Weakness on (B) UE/LE is due to the presence of hypotonicity of
the mm that made him difficult to move his extremities especially in performing
ADLs, ambulation & maintaining static & dynamic standing & sitting.

II. Sensory Assessment

a. Visual Testing
Stimulus used: colored object like red ball to check eye muscle tracking
Findings: homonymous hemianopsia c convergent strabismus
Significance: 20 to CP

b. Auditory Testing
Stimulus used: Calling her name: Good
 Findings:
Significance:

c. Tactile Sensation
Stimulus used:
Findings:
Significance:

d. Perception
Stimulus used:
Findings:
Significance:

III. Reflex assessment

a. DTR/MTR
Legends:
0 Areflexia
+ Hyporeflexia
++ Normoreflexia
+++ Hyperreflexia
++++ Rigidity

Findings: Normoreflexive on (B) UE and Hyperreflexive on (B) LE

Significance: 20 to UMNL

b. Pathological Reflexes
Reflex Stimulus Response
(+) Babinski Stroking of lateral border – Extension of the big
of foot up across ball of toe, flexion & fanning of
the foot. the small toes.
Gonda Squeezing of calf. – No response
Chaddocks Upward stroking of – No response
lateral malleolus.

c. Primitive Reflex
Reflex Stimulus Response
Rooting Stroking around mouth – No response
Flexor Withdrawal Pin on palmar surface of – Flexion of stimulated
hand. extremity
ATNR Head turning to side – No response
STNR Neck flexion and – No response
extension
TLR Patient placed in supine – No increase in
and prone flexor/extensor tone
 IV. Special Test
 (-) Barlow
Findings: negative
Significance:
 (-) Ortolani
Findings:
Significance:

I. Leg ength Measurement

A. True Leg Length Right Left Difference
Greater Trochanter to Medial 32 cm 30 cm 2cm
Malleolus
B. Apparent Leg
Length
Umbilicus to Medial
Mallleolus

II. Head Circumference

Findings: 15cm
Significance: hydrocephalus 20 to spastic CP

ROM Assessment
- Cannot be assisted due to short span attention of the Pt. during execution of
exercise.
III. Functional Muscle Testing (FMT)
Skills Response
Supine to prone 2
Supine to setting 2
Short sitting 3
Sit to stand 2
Prone on elbows/ 2
Prone on hands
Quadruped 3
Creeping 2
Kneeling 2
Tall Kneeling 2
Half Kneeling 2
Standing 2

POSTURAL ANALYSIS
- All bony landmarks are WNA done in supine, except for:
Landmarks Anterior Lateral
Head Head is rotated to (L) Head is extended
 Spine Spine is curved towards (R) Anterior pelvic tilt

Shoulder (B) shoulders are adducted and -

externally rotated
Elbow (B) elbows are flexed, (B) forearms are -
supinated
Wrist (B) wrists are extended; (B) fingers are -
flexed
Hip (B) hips are externally rotated and -
adducted beyond midline (Coxa Valga)
Knee (B) knees are flexed (Genu varum) -
Ankle (B) ankles are dorsiflexed -

Findings: (+) Postural deviation of head d/t muscle weakness and postural deviation of
all other bony landmarks d/t generalized spastic hypotonicity of (B) UE/LE.
Significance: Pt. has difficulty in maintaining erect sitting & standing posture, difficulty in
ambulating independently.

ASSESSMENT:
PT Diagnosis: Impaired motor function, ROM, visual integrity and cognition associated
with Nonprogressive disorders of CNS – congenital origin in infancy.

PT Impression: px was diagnosed with cerebral palsy diplegia, LOM B LE, Leg length
dicrepancy R > L, (+) primitive reflexes (+) homonymous hemianopsia, (+) hypertonicity
of B LE, (+) poor balance, (+) weakness leading to mod. To max assistance 2 to spasticity.

Rehab potential: Pt has a good prognosis d/t:

1. Early detection of pathology
2. Px is active, cooperative and willing during initiation of treatment and exercises
3. Familial support

Problem list:
1. Spasticity on (B) LE
2. Delay motor function (developmental Milestone)
3. Muscle weakness of (B) LE
4. LOM of (B) LE
5. Gait abnormality

LTG:
1. To attain as high as possible functional capacity of the pt as to indep. for 4 mos
2. To maintain the strength of UE for 3 mos
4. To improve cognition, language and social interaction
STG:
1. To increase muscle performance of (B) LE from NF to WF to F for 4 wks
2. To assist the pt develop normal function such as kneeling, walking and stair climbing
for 4 wks

PLAN
Pt. will be seen 3x/wk with the ffg PT Mx:
1. Play therapy
2. Gentle manual stretching exercises on (B) LE x 15 sec hold x 10 reps x 3 sets

HEP:
1. Educate the mother to perform passive ROM exercises
2.Guardian will pull pt from sitting position on floor then repeat for 15x to strengthen trunk.
3.Let the pt walk and play around the house/room with guidance or minimal assistance
by holding him on the pelvis.

Olayvar, Arah A.
Bspt 4