DEPARTMENT OF REHABILITATION MEDICINE

PHYSICAL THERAPY DEPARTMENT

INITIAL EVALUATION
(September 20, 2018)
GENERAL DATA
Name: Jose Ramon Diaz
Age: 71 y/o
Sex: M
Address: Tagaytay City
Civil Status: Married
Occupation: Former vice president of a company
Religion: Catholic
Type of Patient: Out patient
Physician: Dr. Obispo
Dx: s/p CVD Brainstem (2004)
Caregiver’s complain: “ mas hirap na kaming igalaw ang mga joints niya parang lalong
tumitigas o nagiging stiff”
PT Translation: Caregiver complains of difficulty in moving (B) UE and LE of the patient

HPI

Pre morbid status

Pt is Independent in all Aspects of His ADLs and IADLs such as self-care, mobility, transfers
and ambulation

14 years PTIE
Pt was at home with his wife and suddenly complains of dizziness and told his wife to bring him
to the hospital but his wife didn’t believe him and proceeded to the bathroom and took a shower
then suddenly his wife heard a rumble and saw her husband unconscious in their bed she
immediately called an ambulance and after 30 mins the ambulance arrived and the Pt was
rushed to The medical city and was admitted into the ICU for 8 days and was diagnosed to have
CVD (brainstem) PT management was initiated in the ICU then after 8 days Pt was transferred
to a regular room and stayed there for 1 month and PT managements were continuously done
after that the Pt was discharged and continued receiving home PT services for the next 6 mos
2x a week. Pt is unable to work and is dependent in all aspects of ADLs such as self-care,
mobility, transfers and ambulation.
13 years PTIE
Pt’s wife decided to bring the Pt back to Hospital Based PT treatment since her wife noticed little
to no improvements. PT continuously received PT treatment for 8 years in The Medical city. Pt
is still unable to work and is dependent in all aspects of ADLs such as self-care, mobility,
transfers and ambulation.

5 years PTIE
Pt’s wife decided to transfer him to camilos PT clinic where the Pt continued PT treatment for 4
years. Pt is still unable to work and is dependent in all aspects of ADLs such as self-care,
mobility, transfers and ambulation.

3 years PTIE
Pt was discharged from the PT clinic and was prescribed home PT services in tagaytay and
continued it for 2 years. Pt is still unable to work and is dependent in all aspects of ADLs such
as self-care, mobility, transfers and ambulation.

1 week PTIE
Pt’s wife decided to bring him back to a hospital based PT clinic because she noticed that the
patient was regressing and she felt that the home care was not really effective.

At Present
Pt is unable to work and is dependent in all aspects of ADLs such as self-care, mobility,
transfers and ambulation.

PMHx
(+) HTN
(+) Surgery (gall stones removal)
(+) asthma
(-) DM
(-) cancer
(-) OA
(-) RA

FMHx

MATERNAL PATERNAL

HTN (+) (+)

DM (+) (-)

CA (-) (-)

OA (-) (-)
PSEHx
Personal
- Prefers to eat fast food and meat
- Pt loves to read a lot
- Hobbies includes watching tv and listening to music
- Pt has no sleep disturbances
- Pt wears diaper

Social and environmental

- Lives with wife and daughters
- Pt lives in a 2 storey house
- Bedroom is located on ground floor

GENERAL SURVEY
● W/C borne
● Ectomorph
● (+) typical arm posture on (B) UE (SH adducted, elbow flexed, wrist flexed and wrist
ulnar deviated and finger flexed)
● (+) cortical thumb on (B) UE
● (+) SH subluxation on (L) UE
● (+) Postural Deviation
● (-) swelling on (B) UE and LE
● (-) edema on (B) UE and LE

Vital signs
a p

BP (mmHg) 130/90 mmHg 130/80 mmHg

PR (bpm) 66 bpm 74bpm

T⁰ afebrile afebrile

Int: Pt has high BP at baseline and p treatments

Sig: For baseline purposes and treatment precautions d/t pt having (+) HTN

SKIN
● Normal skin turgor, mobility and Consistency
● Normothermic on (B) UE and LE
● (-) discolorations on (B) UE and LE
 ● (-) wounds on (B) UE and LE
● (-) bruise on (B) UE and LE

EXTREMITIES
● (+) grade 2 Spasticity on (B) UE
● (+) deformity on (B) UE and LE
● (+) crepitus on the ® knee
● (+) (L) shoulder subluxation (2 finger breaths)
● (-) tenderness on (B) UE and LE

NEUROLOGICAL EXAMINATION

Mental Status
● Alert (100%) coherent (50%) cooperative (80%)
● Pt communicates through eye and eyebrow movements
● Pt is able to follow simple commands

Tone Assessment
Tone of (B) UE were assessed using Modified Ashworth Scale and are (N) findings except
for:

Muscle Groups (R) (L)

Elbow Flexors 2 2

Knee extensors 1+ 1+

Knee flexors 1+ 1+

Ankle plantarflexors 1+ 1+

Int: patient has spasticity on (B) elbow flexors, knee extensors, knee flexors, and ankle
plantarflexors
Sig.: Pt’s condition is indicative of an UMNL. This also indicates a poor prognosis because pt still
presents c spasticity s/p stroke 14 yrs ago

Legend:
 GRADE DESCRIPTION

0 No ↑ in muscle tone

1 Check and release at the end of the ROM

1+ Catch throughout the remainder (< half of the ROM)

2 Marked ↑ in muscle tone

3 Passive movement is difficult

4 Rigid

Sensory Evaluation:

Superficial Sensation

STD: Dull end for deep pressure, pinprick for pain and brush for light touch

® (L)

Deep pressure 100% 100%

pinprick 100% 100%

Light touch 100% 100%

Int: Pt has intact superficial sensation on (B) UE and LE
Sig: For baseline purposes

Reflex Testing

Pathologic Reflex

Reflex Result Reaction

Babinski (+) extension of the 1st toe and

fanning of lateral toes was
elicited
 Gordon’s (+) extension of the 1st toe and
fanning of lateral toes was
elicited

Openheim (+) extension of the 1st toe and

fanning of lateral toes was
elicited

Int: Pt tested positive in Babinski reflex

Sig: Pt’s condition is indicative of an UMNL

CN Assessment

CN Test Result

Olfactory Smelling of familiar intact

Scents

Optic Confrontation test Intact

Oculomotor, Trochlear, Saccadic and pursuit Intact

Abducens eye movement

Trigeminal Facial Sensation Not assessed

Muscles of
Mastication

Facial Facial expressions Intact

(facial muscle testing)

Vestibulocochlear Hearing (Whisper Not assessed

Test and Rinne Test)
Romberg test

Glossopharyngeal and Swallowing impaired

Vagus

Accessory MMT of Trapezius Not assessed

and SCM
 Hypoglossal Tongue movements intact

Int: Pt has (+) dysphagia and dysarthria

Sig: Pt will have difficulty in communication and swallowing

Reflex Testing

Int: Pt presents c Hyperreflexia of (B) biceps and patellar tendon and clonus on (B) wrist .
Sig: Pt has Hyperreflexia of (B) biceps and patellar tendon, clonus on (B) wrist secondary to
UMNL.

ADL Analysis
*Used FIM

FIM
 Eating 2
Grooming 1
Bathing 1
Dressing Upper Body 1
Dressing Lower Body 1
Toileting 1
Bladder Management 1
Bowel Management 1
Transfer 1
bed/chair/wheelchair
Transfer toilet 1
Transfer bath/shower 1
Locomotion 1
Stairs 1
Motor Subtotal Score 14/91
(max. score 91)
Comprehension 6
Expression 6
Social interaction 1
Problem solving 1
Memory 7
Cognition Subtotal Score 21/35
(max. score 35)
TOTAL FIM SCORE 35/126
(max. score 126)

FIM Performance Levels

1 – Total contact assistance with helper

2 – Maximal contact assistance with helper
3 – Moderate contact assistance with helper
4 – Minimal contact assistance with helper
5 – Supervision or setup with helper
6 – Modified independence with helper
7 – Complete independence

FIM = (Total Score/126) x 100

= 27.78% (Extreme difficulty)

Legend:
0-20 - unable/totally dependent
21-40 - extreme difficulty
41-60 - severe difficulty
61-80 - moderate difficulty
81-99 - mild difficulty
100 - no difficulty/totally independent

Postural Analysis
(done in supine)
All bony landmarks are WNA except:
Anterior and Posterior view Lateral view
(B) SH adducted, elbow flexed, FA pronated, External acoustic meatus is forward in
wrist flexed and finger flexed relation to the acromion process
(L) GH is lower in relation to the ®
(B) Hip flexed, adduced and IR (B) Knees are slightly flexed, ankle are
supinated
Int: Pt has (+) typical arm posture on (B) UE
Sig: Pt will develop further deviations if not corrected

PT Impression
Pt is dependent in all aspects of ADLs as such as, self-care, feeding, transfers, mobility, and
ambulation brought about by impaired muscle performance, (+) muscle spasticity, impaired joint
mobility, hyperreflexive, and (+) postural deviation secondary to s/p CVD brainstem

Prognosis

(+) (-)

Pt ‘s age

Underlying comorbidity (+) HTN

Pt presents c (+) typical arm posture

Pt presents c (+) cortical thumb

(+) Deformity on (B) UE and LE

Area of the brain affected (brainstem)

Pt’s prognosis as to attaining goal is fair. Pt’s condition has been so long. There are also
negative prognosticating factors such as pt’s age, co-morbidities, deformities that will affect the
pt’s prognosis.
LTG
Pt will maintain current functional status as to prevention of secondary complications such as
DVT, contractures, edema and atrophy all throughout PT sessions

Plan Of Care
Problem STG POC

Potential Problems d/t ADL Pt will not present any ● Passive ankle pumps
dependency potential problems p 3 weeks x 10 reps x 1 set
● DVT of PT sessions ● Bed mobility exercises
● Contractures (supine to side-lying
● Edema and v.v.)
● Atrophy ● PROMEs of (B) UE
and LE x 10 reps
● Caregiver education
as to elevation of
● Supine to side-lying c
use of tactile cues and
assistance
● PNF pattern using D1
flexion of UE and LE

Muscle Weakness Pt will maintain muscle ● ES on all major

strength of (B) UE and LE p 4 muscle groups x 60-
weeks of PT sessions 90 contractions
● NMES on all major
muscle groups x 10
mins

LOM Pt will present c increased ● CONT US prior to

ROM of all impaired joint
motion c increments of 10
degrees p 2 weeks of PT
sessions
Pt will not present c further
decrease in ROM of joint
motions c contracture all
throghout PT sessions
stretching x 1.5 w/cm2
x 5 mins
● PROMES of (B) UE
and LE x 10 reps x 2
sets
● GPS on all impaired
joint motion x 30sh x 3
sets

Home Exercise Program

1. PROMEs on (B) UE and LE towards AP x 10 reps
2. Passive ankle pumps x 10 reps
3. Bed mobility/turning every 2 hours
4. Proper positioning and skin care