Philippine Childrens Medical CenterRehabilitation Medicine DivisionPT Section

Initial Evaluation (August September 2013)

Name: Calvez, Hanz NathanAge: 2 1/12 mos.Birthday: 07-17-2011Contact No: 09483438640Dx: Global Developmental Delay secondary to Congenital HypothyroidismRehab MD: Dr. Dela CruzAssociated Medical Condition: nonePresent Meds: LevothyroxineDate of IE: 08 22 - 2013Pt. Classification: Service OPDSchedule: T-TH (2-3pm)

Informant: Mother

S> This is a case of H.C. a 2 y/o 1/12 mos male born at full-term to a then 31 y/o mother c G3P2 (F2-P0-A0-L1) mother via NSD via cephalic presentation @ home assisted by a midwife.

Maternal Hx: Mother is a (-)DM/Asthma/Htn. Mother is a (-) smoker and (+) occasional alcoholic beverage drinker ~1x/yr. Mother is a housewife who usually does all the household chores.

Prenatal Hx: Mother states that pregnancy was planned and wanted; During the 6th mo. of pregnancy, mother underwent ultrasound which yielded breech presentation of the baby. Mother was also dxed c UTI and was advised to take antibiotics for a wk. Mother also had fever and took unprescribed drugs such as biogesic during the 6th mo. of pregnancy. During the 9th mo. of pregnancy, mother underwent ultrasound which yielded cephalic presentation of the baby. Mother states that she had a regular monthly check-up and no other hx of trauma and other illnesses.

Perinatal Hx: Pts mother states that labor was ~2hrs. and underwent NSD. Mother states pt. had 2 ikot na cord coil c unrecalled APGAR score. However, mother described pt. that he cried immediately and pink in color. Mother also stated that the pt. moved his arms and legs.

Post-natal Hx: At 5 mos., mother noticed that pt. cannot roll independently and has difficulty holding head. At 6 mos. mother noticed stiffening of the neck and upward gaze of the eyes which prompted mother to bring pt. to MD. Pt. was then dxed c congenital hypothyroidism and was given Levothyroxine. At 10 mos. mother noticed pt. still cannot hold objects nor sit alone which prompted them to consult MD and was referred for PT Rehab. However, it was only this time they went to Rehab. Pt. also underwent BAER which showed normal results Mother states no hx of trauma and other illness of the pt.

Developmental MilestonesSkillsNormal AgeAge Achieved

Holds head4 mos5 mos

Rolls Over5 6 mos8 mos

Transfers Object6 mos12 mos

Sits alone6-7 mos12 mos

Stands alone10-11 mos13 mos

Walks alone15 mos19 mos.

C/C: Kailangan may hawak pa sa kamay kapag naglalakad siya kasi kapag wala, mabilis siyang matumba.Goal: Sana makalakad siya mag-isa nang matagal tapos hindi natutumba

O > VS > HR: 84 bpm RR: 16 cpm Temp: 36.2 degrees Celsius Sig: Pt. has normal VS. OI > caregiver borne F/D, F/N Microcephalic (46cm) (+) eye deformity (esotropia) (-) gait deviations (-) postural deviations (-) chest deformity (-) facial asymmetry Palpation> normothermic (-) tightness of (B) hamstrings (-) subluxation on (B) UE/LE (-) dislocation on (B) UE/LE (-) edema on (B) UE/LE General Behavior> (+) cries 90% of the time (+) stranger anxiety (+) separation anxiety (+) meaningful eye contact (+) violent actions such as biting, pulling of mothers hair and pinching ROM > All major jts. of (B) UE/LE are WNL passively done c N endfeels Mm tone Assessment > normotonic on all 4s FMT > (+) voluntary movements UE: Pt. can throw 1.1lb ball using (B) UE above shoulder level in standing position c standby assist for ~8-10 reps.Pt. can reach above shoulder level c .5lb weights on (B) wrist in standing position c standby assist for 10 reps.LE: Pt. can do sit to stand exercise c tactile cues on (B) hands in sitting position on a chair c average height for 10 reps. DTRs > (+)normoreflexive on (B) knees and ankles Pathologic Reflexes> (-) Clonus (-) Babinski Sensory Testing > Tactile

StimulusResponse

Light TouchPTs finger brushing on pts legNo response

PainPinch on pts big toe nailWithdraws limb away

PressurePTs finger on pts legNo respose

Visual

ThreatSudden approximation of PTs hand to pts faceCloses (B) eyes

LocalizationToy rattle ~12 inches away from pt.Looks at the toy

TrackingToy rattle ~12 inches away from pt. moving from (R) (L)Looks and follows the toy

Auditory

LocalizationPTs voiceTurns head to PT

PDMS 2SubtestsItemGDescription

A. Reflexes

Walking12Child lifts 1 foot then the other in forward walking movements within 3 sec

Positioning Reflex22Child does not move his or her arms and legs as a result being turned

Landau32Child raises head above horizontal plane, extends trunk and symmetrically raises hips and legs into full extension

Protective Reaction forward42Child extends arms, straightens elbows, and bears weight on open palms.

Protective reaction side52Child breaks fall by extending arm and supporting self with an open palm for 2 sec.

Protecting forward62Child breaks fall by extending one or both arms and supporting self with an open palm for 2 sec

Righting reaction forward72Child breaks fall by extending one or both arms and supporting self with an open palm for 2 sec

Protecting backward82Child stops fall by extending one or both arms backward

RW:16

AE:11 mos.

B. Stationary

172Child raises to sitting position and uses chair for support.

182Child raises to sitting position.

192Child maintains balance for 5 sec while rotating head.

200Child requires help to stand on 1 feet

RW:38

AE:18 mos.

C. Locomotion352Child walks unaided c 5 steps.

362Child picks up toy, returns to standing and walk for 3 steps s losing balance.

372Child creeps up 2 steps with both hands and knees

380Childs walk with wide base of support

390Child remains on 4th step

400Childs remains stationary or drops to hands and knees to ascend stairs

RW:74

AE:14 mos.

D. Object Manipulation32Child throws ball any direction by extending arm at shoulder or elbow

42Child lifts foot and contacts ball.

52Child throw ball by extending arm or shoulders s losing balance

60Child kicks ball and travels less than 3 ft.

RW:10

AE:16 mos.

Fine Motor Skills> (+) RGCR on bilat UE FA > Good dynamic and standing balancePt. was able to do stair negotiation c mod+1 assist on (B) hands for ~2 steps on low-rise stairsBed mobility_7_ rolling to left_7_ rolling to right_7_supine to sitting _7_rolling to proneTransfers_7_ mat to chair/w/c_7_ chair/ w/c to mat_7_ sit to stand_7_ stand to sit _7_ stand pivot

A> PT Dx: MD Dx of GDD secondary to Congenital Hypothyroidism further defined by delayed GMS (stationary: 18 mos., locomotion: 14 mos.,object manipulation: 16 mos.)

Problem List: 1. Delayed Gross Motor Skills2. Muscle weakness of (B) UE/LE3. Good dynamic and standing balance4. Inability to do stair negotiation

Prognosis: Good because pt. is highly functional and his PDMS scores is not that low which can be improved with therapy.

LTG: 1. Pt. will be able to do stair negotiation c contact guard on standard stairs for ~5 steps p 6 mos. PT sessions.2. Caregiver will be able to know precautions and pt. condition and demonstrate HEP properly to further the improvements at home.STG: 3 mos. PT sessions1. Pt. will be able to do stair negotiation c min+1 assist on (B) hands for ~5 steps on low-stairs.2. Pt. will be able to do sit to stand indep for 10 reps x 2 sets using small bench.3. Pt. will be able to demonstrate improved dynamic balance by being able to walk on balance beam for ~2 rounds c sba.

P > Pt. wil be seen 2x/wk and will be given c the ff PTmx:1. STS x 10 reps on average height chair c tactile cues on (B) hands2. Ambulation exercises c 1lb. AW on (B) LE c standby assist on levelled surface x 3 rounds3. Wobble Board exercises x 10 min incorp c reaching activities4. Obstacle course x 3 rounds Throwing using 1.1lb weighted balls in standing position s assist x 10 reps Walking on Balance Beam c close guard x 1 round Stair negotiation on low-rise stairs c mod+1 assist on (B) UE x 1 rounds5. HEP: STS x 10 reps c tactile cues on (B) hands6. Home Instructions: Always talk to the patient for verbal and auditory stimulation. Observe any improvements of the patient during exercises at home. Always ensure patient safety by providing standby assist to supervision at all times during exercise.

________________________________________ Sumalde, Gerald PTRP Pablo, Ceara Mei A. Staff PT In-charge UST PT Intern 2014

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