Endorsement Notes: Cerebral Palsy, Spastic Quadriplegia

Respectfully endorsing Anna Dominique Milan, a 15 1/12 yr old female px who was diagnosed to haves S/P Craniotomy 2 to IV tumor. Px is passive 100% during tx session. Px needs tactile stimulation because usually sleeps during tx time. Px usually comes every MWF 9-10 am with her grandma.

Precaution: seizure due to loud noise and sudden change in position

The PT Mx were:

1. HMP on (B) shoulder x 15mins
2. US on (B) heel cords x 1 MHz x 1 w/cm2 x 5mins
3. GPS on (B)shoulder towards abduction and flexion x 30sh x reps
4. Inhibitory Techniques
1. Alternate knee to chest
2. Pelvic rotation
5. PROME on (B) UE/LE x 10 reps x 1 set, AP
6. NDT’s to improve head and trunk control
1. PTS x 10 reps x 1 set c max assist on (B) shoulders inc stimulation of neck flexors
2. Kneeling x 5mins c +1 max assist on (B) pelvis using stacked wedges
3. POE using pink wedge c jt. Compression on (B) shoulder x 5mins
4. Long sitting x 10 mins c (B) ahnds propped forward c PKS on (B) UE c jt. approcximation on (B) shoulders à GPS of trunk towards (L) x 30sh x 3 reps
7. Tilt table x 10 mins

Dominic S. Adolfo

PLM PT INTERN 2008

Rajawen Africa, PTRP

PT Staff – in Charge

PT Initial Evaluation : Plantar Fasciitis

Pamantasan ng Lungsod ng Maynila

General Luna St., Intramuros Manila

PHYSICAL THERAPY INITIAL EVALUATION

General Information:

Pt.’s Name: S.V.

Age: 25 yrs. old

Sex: Female

Address: Sta. Ana, Manila

Civil Status: Single

Handedness: ®

Occupation: Elementary School Teacher

Religion: Roman Catholic

Referring Doctor: Dr. P.G.

Referring Unit: PGH

Date of Referral: February 10, 2007

Date of IE: February 13, 2007

Informant/Reliability: Pt./God

Dx: (L) Plantar Fascitis

HPI:

Present condition started 3 mos. PTC when pt. felt uneasiness on her (L) foot accompanied by pain P/S (2/10) in doing walking activities after taking off her shoes. She ignored the condition thinking that it was only due to prolonged standing. The pain was relieved by liniments and upon resting.

1 mo. PTC, pt. experienced pain P/S (5/10) even after resting. She has now moderate difficulty in doing walking activities aggravated when she’s barefooted. At work, she takes Ponstan 250 prn to control the pain decreasing the P/S by 2-3 grades. At home, she also soaks her foot into a basin of warm water since it eases the discomfort.

1 wk. PTC, pt. presents severe pain P/S (8/10) and has difficulty making her first step out of bed. She cannot tolerate any prolonged walking and even wt. bearing (standing) activities. The pain reliever she was taking cannot control the pain anymore so she decided take a leave from work for a few days. Her condition didn’t get any better. She immediately went to PGH for medical advice. The doctor gave her steroids for temporary relief. She was then referred to rehabilitation department.

At present, pt. will start PT tx.

Drug Hx:

Drug	Administration	Dosage	Frequency	Indication	Date
Tiger Balm	Topical	------------	prn	Mm pain	Nov-Dec 2007
Ponstan	Oral	250	prn	Pain relief	Dec-Feb 2007
Steroids	Subcutaneous		Once	Pain relief	Feb 2007

Ancillary Procedure:

Radiograph findings are negative of heel spurs and other anomalies that can lead to heel pain.

PMHx:

· (-) Burn

· (-) Scars

· (-) Achilles tendon tear

· (-) Ankle Sprain

PSEHx:

· Type B personality

· Works 8 hrs a day

· Walks 500 meters a day

· Wears 3 inches of heels

· Lives c her parents

· Good financial status

· Primary caregiver: parents

S:

C/c: “ I cannot tolerate the pain whenever I walk or even with merely standing. It’s hard for me to work.”

PT Translation: Pt. has difficulty in doing ADLs due to pain.

Pt.’s Goal: To return to work without any limitations and pain-free.

O:

VS:

	a	during	p
BP	120/80	120/80	120/80
PR	60 bpm	75bpm	80 bpm
RR	13 cpm	13cpm	15cpm
T	36	37	37

OI:

· Ectomorph

· Ambulates independently

· (+) Gait deviation – see Gait Analysis

· (+) Postural deviation – see Postural Analysis

· (+) erythema on (L) plantar and medial aspect of the foot

· (-) scars on all exposed body parts

Palpation:

· (+) tenderness on (L) medial tubercle

· (+) hyperthermia on (L) plantar aspect and medial tubercle

· (-) subluxation

· (-) crepitation

Significance: Presence of inflammation

Tone A:

Normoreflexia on (L) ankle

Superficial Sensation:

Pin – for pain

Brush- for light touch

Thumb- for pressure

Findings: Intact sensation on (L) ankle

Significance: Intact sensory pathway

MSR:

(R) (L)

Legend:

0 - areflexia

+ - hyporeflexia

++ - normoreflexia

+++ - hypereflexia

++++ - clonus

Findings: Normoreflexive at all tested areas

ROM:

All major jts. are grossly assessed passively and actively done and are WNL and pain free except for:

(L) Ankle

Motion	Active	Passive	(N) Range	Difference	End-feel
Dorsiflexion	0-5 deg	0-10deg	0-15 deg	10 deg	firm

Significance: Limitation of motion was due to pain. Patient only presents with protective LOM.

MMT:

All major mm of the body was grossly assessed and were graded 5/5 except for:

· Ankle dorsiflexion – 4/5

Note: MMT of the ankle dorsiflexors were taken with in pain free limits.

Significance: There is no true mm weakness.

Special Test:

(-) Thompson Test

Findings: Plantar flexion occurred upon calf squeezing.

Significance: to R/O presence of Achilles tendon rupture.

(-)Prone Anterior Drawer test of the Ankle

Findings: No excessive anterior motion of the ankle occurred during test.

Significance: to R/O possible ankle sprain or ligamentous instability.

(-) Talar tilt

Findings: No excessive medial and lateral motion of the ankle occurred during the test.

Significance: to R/O possible deltoid and calcaneofibular ligament instability.

Postural Analysis:

All parameters of posture are assessed and WNL.

Gait Analysis:

Phases	(L)	®
Stance Phase	· decrease initial contact and loading response · decrease midstance and terminal stance	· increase initial contact and loading response · increase midstance and terminal stance
Swing Phase	· increase swing phase	· decrease swing phase

Significance: Pt. presents c antalgic gait. Wt bearing is increase on the unaffected side, avoiding painful heel strike and wt. bearing on (L) extremity.

Standing Tolerance & Balance:

Grading:

Tolerance

Normal – 60 min.

Good – 45-60 min

Fair – 15-30 min

Poor – 0-15 min

Nil – none

Balance

Normal – can assume, maintain, wt shift and be challenge

Good – can assume, maintain and wt shift

Fair - can assume and maintain

Poor – can assume

Nil – none

Findings: Pt. has normal balance and poor standing tolerance.

Significance: Pt.’s poor tolerance was due to pain.

ADL Analysis:

All aspects of ADL are independently done except for:

– Walking – presents c moderate difficulty

Significance: Pt.’s moderate difficulty in walking was due to pain.

A:

Dx: Plantar Fascitis of (L) heel

PT impression: Plantar fascitis on (L) LE of pt makes WB as well as ambulation moderately difficult.

Rehab Potential: Good, because the condition can be resolve through conservative treatment within 3 mo. and there was absence of heel spurs.

Problem List:

1. Pain c a (P/S 8/10) of (L) plantar aspect of foot.
2. Limited (L) ankle dorsiflexion because of pain
3. Poor standing tolerance
4. Moderate difficulty on doing ADL’s especially walking
5. (+) Gait deviation
6. False weakness of ankle (L) Dorsiflexors

LTG:

1. To be able to achieve highest functional activity and pain free after 15 tx sessions.

STG:

1. To decrease pain from ( P/S 8/10-3/10) after 7 tx session

2. Improve ankle dorsiclexion of (L) foot from 5 to 15 degrees 15 after 5tx session

3. Increase standing/balance tolerance from fair to good after 5 tx session

4. Improve ADL esp. in walking for 7 tx session

5. Improve gait pattern after 5 tx session

P:

Intervention for the 1^st 4 tx session

1. Cryocuff on (L) heel for 15 min.

2. Conventional TENS for pain on (L) heel

3. Bandaging on (L) heel ADA (Ankle Dorsiflexion Assist) Technique

Continuing Program

1. Deep friction massage for 20 min.
2. Bent knee exercises 5 reps x 3 sets to stretch the plantar aponeurosis
3. Bottle Rolling using the feet for 10 reps to loosen up plantar fascia
4. Recommend using heel pads and plastic heel cups

HI

1. Encourage patient to exercise the foot using towel wrinkling, picking up objects c the use of toes.
2. Do ative ankle dorsiflexion at home for at least 10 reps
3. Encourage pt to wear flat foot wear.

Abelardo, Camille Eunice

Adolfo, Dominic

Bartolome, Karen

Britanico, Maria Socorro

Librando, Kristine Zarah

Discharge Notes: Fracture

Pamantasan ng Lungsod ng Maynila

College of Physical Therapy

PLM-CBR

Respectfully endorsing for discharge Bryan Duterte, a 8 yr old male patient who was diagnosed to have Fx Closed,Complete,Displaced Distal TibioFemoral ®.

Present Problem Lists:

1. Gait deviation manifested by slight calcaneovalgus ® during ambulation
2. Good to Normal mm grade of ankle plantarflexors ®

Present PT Mx:

1. Heel walking x 5 rounds around the PT Clinic
2. Toe walking x 5 rounds around the PT Clinic
3. Trampoline Exercises:
1. Standing one leg with eyes open/eyes close depends on px tolerance
2. Jumping on both legs to one leg x 10 reps

Px was seen and treated 4 times for 2 months since August 2007. Px was sometimes playful and shy but very cooperative during tx session. P was discharged due to mark increase in mm weakness, Normal ROM and improvement in gait.

Dominic S. Adolfo

PLM PT Intern 2008

PT Initial Evaluation:Low Back Pain 2 to Lumbar Spondylosis

Pamantasan ng Lungsod ng Maynila

College of Physical Therapy

PLM-CBR

Pt.'s Name: Dolores Liwag

Age: 61

Sex: F

Address: Manila

Civil status: Married

Handedness: ®

Occupation: Dean of PLM

Religion: Roman Catholic

Rehab Unit: PLM-CBR

Rehab Dr.: Dr. Ynion

Date of Consultation: AUG. 6, 2007

Date of IE: AUG. 12, 2007

Type of pt.: Outpt.

Informant/Reliability: Pt./Good

Dx: Lumbar Spondylosis

HPI:

Present condition started 2 months PTIE when px felt localized dull aching pain on ® low back area c PS (5/10) upon prolonged sitting while doing office works. Px was then rested after office hours and took Alaxan (see drug hx) which relieved the pain from PS (5/10) to PS (2/10). Px was able to tolerate her condition for 6 week and took same medication prn.

Two weeks PTIE, due to severity of pain PS (8/10), px seek consultation in PLM-CBR and was diagnosed to have LBP. The rehab doctor prescribed px to take Mobic (see drug hx) and was referred for PT for further evaluation and tx.

At present, px is independent in all aspects of ADL’s except in prolonged sitting during office works due to pain on ® low back area.

Ancillary Procedures

Result Date

Bone Scan decrease bone density unrecalled

MRI spinal stenosis of L4, L5 unrecalled

Drug Hx:

Indication Dosage

Alaxan pain reliever 500 mg

Mobic pain reliever unrecalled

PMHx:

(-) Htn

(-) DM

(-) heart dse.

(-) asthma

(-)arthritis on all 4’s

FMHx:

Father Mother

Htn. (-) (+)

DM (-) (-)

Heart Dse. (-) (-)

Asthma (-) (+)

PSEHx:

type A personality (px has an active lifestyle and goes to gym twice a week for fitness and work out)

non cigarette smoker

non alcohol beverage drinker

Good financial support

Px was a dean of PLM

Lives in a 2 storey house c husband

Hobbies: watching tv and going to gym

Px work almost 6-8 hrs/day and sit 4-5 hours daily

S: c/c: Pt. c/o localized dull aching pain on ® low back c PS(7/10). Px also /co min difficulty in doing office works such as prolonged sitting due to pain on ® low back.

Pt.'s Goal: To be able to work pain free and s difficulty.

O:

VS: BP: p 120/70 mmHg

a 130/90 mmHg

PR: 75 bpm 80 bpm

RR: 17 cpm 18 cpm

Temp.: Afebrile to touch

OI:

Ambulatory s assistive device

Endomorph

alert, coherent, cooperative

(-) gait deviation

(-) postural deviation

(-) swelling, erythema, hematoma, scar, wound and skin trophic changes in all 4’s face and trunk

Palpation:

Normothermic on all exposed body parts

(+) Grade 1 tenderness on ® low back area

(+) nodules on ® low back area

(+) taut bands on ® low back area

(+) mm spasm on ® low back area and ® upper quadrant of gluteal

(-) edema, subluxation,crepitition and dislocation on all 4’s

ROM:

All major jts. of (B) UE?LE are WNL, actively and passively done, painfree and c (N)

endfeel, except on (B) hip extensor noted hypermobility c firm end feel.

Significance: mm imbalances may cause the LBP

MMT:

All major mm of (B) UE/LE and trunk were grossly graded 5/5.

Significance: Px can perform exercises s difficulty

Special Test:

(+) Bragard’s Test

Findings: pain upon passive knee extension c hip extension and ankle dorsiflexion

Sig: possible nerve affectation

(+) Turyn’s Test

Findings: pain upon doing the test

Sig: possible nerve affectation

DTR

Findings: Normoreflexive on all tested areas

Sig: Intact reflex arch

Sensory Assessment:

Superficial:

STD used: pin - pain

brush - light touch

thumb - pressure

Findings: intact sensation on (B) LE

Sig: Thermal modalities may be suggested for tx

Functional Analysis

Sitting B/T: N/N

Standing B/T: N/N

ADL Analysis:

All parameters of ADL’s especially bathing, eating, dressing and housekeeping are done independently except working c min difficulty on prolonged sitting due to pain on ® low back.\

A:

PT Impression: Px’s improper posture, prolonged sitting and mm imbalances of (B) hamstring caused the LBP. This is also further manifested by MRI who revealed px has lumbar spondylosis and spinal stenosis of L5-S1.

Rehab Potential: Pt. has fair rehab potential. Pain management and proper exercise prescription may benefit but the course of the condition was due to aging. Px is not also compliant to the tx.

Problem Lists:

1. localized dull aching pain on ® low back c PS (8/10)
2. min difficulty in office works due to prolonged sitting
3. hypermobility of hip extensor
4. nodules on ® low back are
5. taut bands ® low back area
6. mm spasm on ® low back area and ® upper quadrant of gluteal
7. Grade 1 Tenderness on ® low back area

LTG: (in 2 mo.)

Px will be able to do office works c tolerated pain to pain free and s difficulty

STG: (in 1 mo):

1. To decrease pain ® low back area from PS (8/10) to PS (4/10) in 4 tx sessions
2. To be able to do office works s difficulty in 4-6 tx sessions
3. To correct px’s mm imbalance in 4-6 tx sessions
4. To decrease taut bands in 4 tx sessions
5. To decrease nodules in 4 tx sessions
6. To eliminate mm spasm in 4 tx sessions
7. To eliminate tenderness in 4 tx sessions

P:

PT Mx:

1. HMP/Tens on ® low back area x 20 mins to decrease pain and mm spasm
2. UTZ on ® low back area x 1.5 w/cm ² x 5mins prior to exercise and to decrease pain and mm spasm.
3. McKenzie Extension Exercises (1 and 2) x 30 sh x 5 reps to strengthen abdominals
4. Low back effleurage massage x 5 mins to decrease pain and mm spasm and to relax the back extensor mm
5. Hamstring, Piriformis and Rectus Femoris Stretching x 30 sh x 10 reps to increase ROM

HI:

1. Put a hot towel or hot bottle if px feel pain on ® low back
2. Proper Body Mechanics
3. Follow the exercises taught in by the PT

Dominic S. Adolfo

PLM PT Intern 2008

PT Life