STA.
ANA HOSPITAL
DEPARTMENT OF REHABILITATION MEDICINE
PHYSICAL THERAPY SECTION
2629 New Panaderos St. Sta Ana Manila
Tel. no.: 516-61-51
INITIAL EVALUATION
June 4, 2019
GENERAL INFORMATION:
Patient’s Name: Santos, Steven John
Age: 6yrs and 11 mos.
Sex: M
Address:
Citizenship:
Handedness:
Occupation: Student
Date of birth: July 19, 2012
Date of IE:
MD Dx: GDD
Referring MD:
Referring Unit:
Rehab MD: Dr. Cely Aguilera , MD
Rehab Unit: SAH-Department of Physical Therapy
Informant/ Reliability: Pt’s Mother/Good
Precaution:
Mother’s Complaint: “”
PT Translation:
Mother’s Goal: “”
PT Translation
HPI:
Hx ng pregnancy
~6 yrs PTIE, Pt was hospitalized for 2 wks d/t pneumonia and increased blood sugar. 2 weeks after hospitalization, pt.
was rushed to the hospital d/t seizures.
~5yrs PTIE, when pt was 11 mos, Pt’s mother noticed that her child was delayed in gross motor compared to other kids
and had her child medically Dx with GDD. Pt. received PT treatments for ~a year and then stopped.
~2yrs ago, pt. received PT treatments for ~a year in UPM and then stopped.
At present, pt presents c weakness in (B) LE and pelvis, moves by mermaid crawling, cannot stand and walk c
assistance.
HPI:
Ancillary Procedure:
Date Taken Results Significance
CT scan Unrecalled Asymmetric brain?
MATERNAL Hx:
● Age of mother: 23
● Unplanned pregnancy
● (-) Check-ups
● (-) Bleeding
● (-) Infection/ Illness
● (-) Smoker:
● (-) Alcohol drinker
● (-) intake of abortive drugs
● (-) accidents/trauma/ hospitalization/ medical problems
● 2 Hrs of labor
● Gravida, PARA: 1-1-0-0-0-0
BIRTH Hx:
Apgar scale
2 1 0
Mm Tone Active Arms & legs flexed Absent
Pulse >100 bpm <100 bpm Absent
Reflex Irritability Sneezes, coughs, pulls away Grimaces NR
Appearance (N) (N) except limbs Cyanotic or pale
Respirations Good, crying Slow, irregular Absent
● Apgar: Mother’s explanation on what she recalled (no Apgar if mother did not remember); Score:
● Term:
● Type of delivery: Normal delivery
● Type of presentation: Cephalic/ breech/ shoulder presentation
Place: home/ hospital/others; Assisted by: doctor/ midwife/ nurse/ others
● Wt.:
● Length:
NUTRITIONAL Hx:
● () Feeding problems
● Breastfed for 2 weeks
● Bottle fed since
● Semi solid food since
● Solid food since
IMMUNIZATION Hx:
Age of Patient Date Vaccine
At birth Unrecalled BCG vaccine
2 mos. old Unrecalled DPT1
3 mos. old Unrecalled DPT 2
4 mos. old Unrecalled OVP 2, DPT 3
6 mos. old Unrecalled OVP 3
9 mos. old Unrecalled Hepa-B1
10 mos. old Unrecalled Hepa-B2
11 mos. old Unrecalled Hepa- B3
12 mos. old Unrecalled MMR
Patient has complete immunization and boosters as stated by mother
DEVELOPMENTAL MILESTONES:
Source: Molnar
Motor Ability Normal Findings
Turns head 3 months Unrecalled
Good head control 4 months 1y/o
Rolls Over (Prone To Supine) 3-6 mos. 2y/o
Rolls Over (Supine to Prone) 6 months. 2y/o
Maintain sitting 7 months 2y/o
Prone On Elbow 3-6 months. 2y/o
Prone On Hands 6-9 months. 2y/o
Creeps 10 months 2y/o
Stand momentarily 10 months 2y/o
Grasp Feet 7 mos.
Hips Pivot in Prone Position 8 mos.
Sits Alone 6-7mos 2y/o
Chronological Age:
Developmental Age:
Age of Delay: Chronological - Develeopmental age
PMHx:
● (+) Hospitalization
● (+) Seizures + duration
Medication:
● (-) surgery
OCULAR INSPECTION:
⮚ Non/Ambulatory, Mother-borne
⮚ Level of Consciousness/Understanding
o Awake
o Alert
⮚ Normo/Micro/Macrocephalic
⮚ Ectomorph, Poorly/Fairly/Well Nourished
⮚ (+) Postural deviations (See PA)
⮚ () Meaningful eye contact
⮚ (+) drooling (position)
⮚ () Tongue Thrusting
⮚ (-) Cortical Thumb
⮚ (-) Eye Deviation:
⮚ (-) Flexion/Extension Synergies on B UE/LE
⮚ (+) Leg-length discrepancy (See Anthropometric Measurements)
⮚ (+) Callous on (R) dorsum of hand
Deformities: limb/eyes
⮚ (-) Bird wing posturing
⮚ (-) Strap hanger posturing
⮚ (-) Pithed-Frog posturing
⮚ (-) Opisthotonus Posturing
⮚ Pre-linguistic Communication:
⮚ Attentive / Cooperative / Cries / Passive / Hyperactive / Manipulative _____% of the time during evaluation
procedure
⮚ Poor / Good Attention Span
⮚ Poor / Fair / Good Concentration Span
⮚ Poor / Fair / Good Frustration Tolerance
⮚ (impulse control)
⮚ (-) Separation / Stranger Anxiety
⮚ (-) Self-Injurious
⮚ No purposeful hand movement
⮚ (others)
PALPATION:
⮚ Normo / Hyper / Hypo -thermic on all exposed body parts
⮚ Hyper / Normo / Hypo -tonic on (B) UE/LE
⮚ () Crepitus on
⮚ () Tenderness on
⮚ () Contracture on
⮚ () Tightness on
⮚ () Dislocation on
⮚ () Subluxation on
⮚ () Edema
NEUROLOGIC EXAMINATION:
A. Sensory Assessment:
1. Tactile Testing:
a. Light touch
● STD used:
● Response:
b. Deep pressure
● STD used:
● Response:
c. Pain
● STD used:
● Response:
Significance:
2. Auditory testing:
a. ATD used:
Response:
Significance:
3. Visual testing:
a. Tracking
● VTD used: Blue & white thermometer
● Response: Pt's eyes followed the direction of the thermometer.
b. Threat
● VTD used:
● Response:
Significance:
B. Reflex Testing
A. DTRs
Legend:
0 – Areflexive
+ - Hyporeflexive
++ - Normoreflexive
+++ - Hyperreflexive
++++ - Clonus
Findings:
Significance:
a. Pathologic Reflexes
➢ () Clonus
➢ (+) Babinski
● (+) Chaddocks
● () Oppenheim on
● () Gordon on
b. Primitive Reflexes
Reflexes Result
ATNR ()
SNTR ()
Moro ()
Neck Righting ()
Extensor Thrust ()
Foot Placement (+)
Parachute ()
TONE ASSESSMENT:
TONE ASSESSMENT
Legend
0 No response (Flaccid)
1+ Dec. Response (Hypotonia)
2+ Normal Response (Normotonia)
3+ Exaggerated Response (Mild to Moderate Hypertonia)
4+ Sustained Response (Severe Hypotonia)
All major muscle groups of (B) UE & LE were assessed and were found to be:
Muscle group (R) (L)
Shoulder Flexors 2+ 2+
Shoulder Extensors 2+ 2+
Shoulder Abductors 2+ 2+
Elbow Flexors 2+ 2+
Forearm Supinator 2+ 2+
Wrist Flexors 2+ 2+
Wrist Extensors 2+ 2+
Hip Flexors 2+ 2+
Hip Abductors 2+ 2+
Knee Flexors 2+ 2+
Ankle Dorsiflexors 2+ 2+
Ankle Plantarflexors 2+ 2+
Toe Extensors 2+ 2+
Findings:
Significance:
SPASTICITY ASSESSMENT:
Modified Ashworth Scale for Spasticity:
0 – No increase in muscle tone
Findings:
1- Slight increase in muscle tone manifested by a catch and release or by minimal
⮚ T
resistance at the end of the ROM when the affected part is moved in flexion or
⮚ T
extension
⮚ T
1+ - Slight increase in muscle tone manifested by a catch followed by minimal
⮚ T
resistance throughout the remainder (less than half) of the ROM
2 – More marked increase in muscle tone through most of the ROM but the
affected part/s is/are easily moved
3 – Considerable increase in muscle tone, passive movement is difficult
4 – Affected part/s is/are rigid in flexion or extension
RANGE OF MOTION:
All major joints of head, trunk and (B) UE & LE were passively assessed and were found to be WNL, except:
Motion (N) Value AROM PROM AROM PROM End-Feel
Difference Difference
(R) (L) (R) (L) (R) (L) (R) (L)
Shoulder flexion 0-180° Firm
Shoulder 0-60° Firm
extension
Shoulder 0-180° Firm
abduction
Shoulder ER 0-90° Firm
Shoulder IR 0-90° Firm
Elbow flexion 0-150° Soft
Elbow extension 150-0° Hard
Forearm 0-80° Hard
pronation
Forearm 0-80° Firm
supination
Wrist flexion 0-80° Firm
Wrist extension 0-70° Firm
Wrist radial 0-20° Hard
deviation
Wrist ulnar 0-30° Firm
deviation
Finger MCP 0-90° Firm
flexion
Hip Flexion 0-120° Soft
Hip Extension 0- 20° Firm
Hip Abduction 0-40° Firm
Hip Adduction 0-20° Firm
Hip ER 0- 45° Firm
Hip IR 0- 45° Firm
Knee Flexion 0-135° Soft
Knee Extension 135-0° Firm
Ankle 0-20° Firm
Dorsiflexion
Ankle Plantar 0-50° Firm
flexion
Foot Inversion 0-35° Firm
Foot Eversion 0-15° Firm
1st MTP flexion 0-45° Firm
1st MTP 0-70° Firm
extension
Findings:
Significance:
FUNCTIONAL MUSCLE TESTING:
Grading: Balance: Tolerance:
FMT: 1 – cannot assume or maintain Poor – 0 to 15’
0 – no ability 2 – can assume but not maintain or Fair – 16 to 30’
1 – beginning ability, partially achieved, vice versa Good – 31 to 45’
unreliable, insecure momentary 3 – can assume & maintain Normal – 46 to 60’
2 – reliable c abN pattern 4 – can assume, maintain, weight
3 – reliability achieved, efficient, reliable c shift & can be challenged
good pattern
Motion Grade Description
Head control
Trunk control
Rolling prone →
supine
Rolling supine →
prone
Prone on Elbows
Creeping
Crawling
Quadruped
Sitting assume
Sitting B/T
Kneeling assume
Kneeling B/T
Half kneeling assume
Half kneeling B/T
Standing
Standing B/T
Findings:
Significance:
REACH, GRASP AND RELEASE:
(R) (L) Grading:
Reach () () RGR:
Grasp () () Poor - (-) RGR or (+) Reach but (-) Grasp and Release
Release () () Fair - (+) Reach and Grasp with difficulty in Releasing or (+)
Findings: Reach with difficulty in Grasping and Releasing
Significance: Good - Complete RGR or (+) RGR
LEG LENGTH MEASUREMENT:
Landmarks (R) (L) Difference
TLL ASIS to medial malleolus 62cm 60cm 2cm
ALL Umbilicus to medial malleolus
Segmental ⮚ ASIS to Greater Trochanter
⮚ Greater Trochanter to Lateral
Femoral Condyle
⮚ Medial Tibial Plateau to Medial
Malleolus
Findings:
Significance:
HEAD CIRCUMFERENCE:
Landmarks: Glabella, Supraorbital fissure, Occiput
N: After 12 mos=47cm & Adult=57cm
Result: 48cm
Findings:
Significance:
SPECIAL TESTS:
Tests (R) (L) Significance
⮚ () Thomas () ilipsoas tightness
⮚ () Silverskiold () gastrocnemius tightness
⮚ () Galeazzi () hip dislocation
() leg-length discrepancy
⮚ () Staheli () iliopsoas tightness
⮚ () Phelps-Gracilis () adductor spasticity
⮚ () Ely’s Test () rectus femoris tightness
⮚ () Popliteal-Angle () hamstring tightness
PROGNOSIS FOR AMBULATION:
Grading:
Good:
Able to sit at 2y/o
Able t ostand at 4
y/o
Absent
primitive/infantile
reflexes at 18-24 mos.
Fair
Able to sit at 3y/o
Able to stand at 5y/o
Poor
Able to sit at 4 y/o
Able to stand at 6y/o
(N) Findings Score
ATNR
STNR
MORO
Extensor Thrust
Neck Righting
Parachute Reaction
Foot Placement
Findings:
Significance:
EQUILIBRIUM REACTION:
Lateral
Position Reaction Anterior Posterior
(R) (L)
Saving
Sitting
Tilting
Findings:
Significance:
POSTURAL ANALYSIS
All postural landmarks are within normal alignment except for the following assessed in supine and prone
using the following views:
Lateral
Landmark Anterior Posterior
(R) (L)
Head
Shoulders
Scapula
Elbow
Hands
Trunk
Spine
Pelvis
Hips
Knee
Ankle & foot
Findings:
Significance:
GAIT ASSESSMENT:
HS FF MS HO TO
Hip ↑/↓ ↑/↓ ↑/↓ ↑/↓ ↑/↓
Knee ↑/↓ ↑/↓ ↑/↓ ↑/↓ ↑/↓
Ankle ↑/↓ ↑/↓ ↑/↓ ↑/↓ ↑/↓
ACCELERATION – MIDSWING MIDSWING - DECELERATION
Hip ↑/↓ ↑/↓
Knee ↑/↓ ↑/↓
Ankle ↑/↓ ↑/↓
Findings:
Significance:
ACTIVITIES OF DAILY LIVING ANALYSIS:
➢ H
➢
A. ASSESSMENT:
● Diagnosis:
● PT Impression:
⮚
● Problem List:
1. T
2.
D. PLAN:
LONG-TERM GOAL: (~time frame)
➢ To
➢
SHORT-TERM GOALS WITH PT MANAGEMENT:
EXERCISE INTEGRATED AT HOME
STG MANAGEMENT
To the Mother/Father/Caregiver
HOME INSTRUCTIONS:
➢
RECOMMENDATIONS:
⮚ V
Name: Steven John Santos
Address: Sta Ana, Manila
Age: 6
Date of IE: July 19, 2018
Informant/Reliability: Mother/ Good
Dx: GDD
Sex: Male
Mother’s Complaint: “Mahina yung legs niya”
PT Translation
Mother’s Goal: “Sana makatayo siya magisa”
PT Translation
HPI:
~6 yrs PTIE, Pt was hospitalized for 2 wks d/t pneumonia and increased blood sugar.
~5yrs PTIE, when pt was 11 mos, Pt’s mother noticed that her child was delayed in gross motor compared to other kids
and had her child medically Dx with GDD. Pt. received PT treatments for a year and then stopped.
~2yrs ago, pt. received PT treatments for a year in UPM and then stopped.
At present, pt presents c weakness in (B) LE and pelvis, moves by mermaid crawling, cannot stand and walk c
assistance.
Ancillary Date Place Findings Impression
Procedure
CT Scan Unrecalled - Assymetrical
MATERNAL HISTORY
Prenatal
● Age of mother: 29 yrs old
● Unplanned pregnancy?? (DID NOT KNOW SHE WAS PREGNANT, only knew when she was already in japan
for a month)
● Regular menstruation before pregnancy
● Non-smoker
● Non- alcoholic drinker
● Labor hours: ~ 6 hours
● Gravida 1, Para 4-0-0-0-0
Birth History
● Breastfed for 2 weeks
FMHx:
Paternal Maternal
DM (-) (-)
HPN (-) (-)
Asthma (-) (+)
Global Developmental Delayed (-) (-)
PSEHx:
Personal
● Pt. watches videos on tablet
● Pt. likes to play with toys that has sounds
● Pt lives with mother
● Pt plays alone
DEVELOPMENTAL MILESTONES
Gross Motor Abilities Normal year achieved Year achieved
Turns head 3 months 3 months
Good head control 4 months ~ 2 y/o
Rolling Prone to Supine 4 months ~ 2 y/o
Rolling Supine to Prone 7 months ~ 2 y/o
Maintain sitting 7 months Not yet achieved
POE/POH (Prone on elbows/Prone 10 months ~ 3 y/o
on hands)
Creeps/crawls 10 months Not yet achieved
Stands momentarily 10 months Not yet achieved
Walks alone 14 months Not yet achieved
Seat self in chair 18 months Not yet achieved
Walks backward 18 months Not yet achieved
Begins running 2 years Not yet achieved
Jumps in place 2 years Not yet achieved
Fine Motor Ability Normal Year Achieved Achieved at/ Description
Palmar grasp Newborn Newborn and persistent until now
Crude palmar grasp, midline 4 months Not yet achieved
handplay
Intermediate grasp and tranfers 7 months Not yet achieved
object form one hand to the other
Pincer grasp (thumb to index finger) 10 months Not yet achieved
Holds crayon full length, scribbles 14 months Not yet achieved
Holds crayon butt-end, raisin 18 months Not yet achieved
dumpling in bottle
Draws vertical line (2.5 – horizontal) 2 y/o Not yet achieved
Circle 3 y/o Not yet achieved
● Chronological age: 6 years old
● Developmental age:
● Age delayed:
