IPT December 08, 2011 Patients 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:

Legend: 0- Areflexia IHyporeflexia IINormorelexia IIIHyperreflexia IVClonus

Findings: Hyperrelexia on (B) UE and LE * note: foot was not assessed due to clubfoot defority Sig.: 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, ankle dorsiflexors and plantar flexion Sig: LOM secondary to Mm contracture, 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

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- Complete independence 6-Modified independence 5-Supervision 4- Minimum assist 3-Moderate assist 2-Maximim assist 1-total assist

Finding: Dependency on self-care, toileting, 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. During and after the PT session Problem list: 1. LOM on (B) shoulder flexion, (B) knee extension, ankle dorsiflexors and plantar flexion 2. Atrophy of (B) UE/LE 3. Spasticity on (B) UE/LE 4. Flexion contracture on (B) knees 5. Deformity on clubfoot 6. Hypereflexive on (B) UE/LE 7. Dependency on self-care, toileting, transfer and locomotion Goals 1. To achieve highest possible ROM on LOM on (B) shoulder flexion, (B) knee extension, ankle dorsiflexors and plantar flexion 2. To prevent any further atrophy of (B) UE/LE 3. Prevent any further spasticity on (B) UE/LE 4. To prevent further flexion contracture on (B) knees 5. To retard deformity on clubfoot P: PT Management: 1.PRE X 15 reps X 1set on (B) UE/LE c 5 lbs DB and LAW(AP) 2. Stretching exercise X 15shX 10 reps X 1set on (L) ankle DF 3. Pelvic bridging X 10 sh X 10 reps X 1set 4. Sitting push-up X 7sh X 10reps X 1set

Approve By: Vilma A Ramos, PTRP Chief PT

Prepared By: Christian G. Lacson PT Intern 12