Initial Evaluation

NAME: Eduardo Cantillo DATE OF I.E: December 12,2018

SEX: ♂ DATE OF Adm: September 28,2018
ADDRESS:8-D figuero St. Sawang, Calero,Cebu DATE OF REFERRAL: November 7,2018
DOB:March 31,1965 REFERRING MD: Unrecalled
CONTACT NO: 09324493201 PHYSIATRIST: Dr.Erich Canazares
NATIONALITY:Filipino Dx. CVD infract c ® sided residuals
RELIGION: Roman Catholic Meds: Amlodepine 10mg & angiostatin to be
OCCUPATION: Warehouse worker taken every a.m. q.d. ; vitamins (name
HANDEDNESS: ® unrecalled) taken p.m. q.d
CIVIL STATUS: Married
/S/: (note: Some significant informations & dates was taken from significant other.)
C/C:Pt. complains of inability to move L UE & weakness on both L UE & LE.
HPI:Pt.’s current condition started on Sept. 28,2018, when he suddenly felt weakness of L UE &
began having difficulty speaking; was brought by wife to Dr. Jeffrey Lawas Clinic & was adviced
& brought to Vicente Sotto Memorial Medical Center ( VSMMC) . Pt was admitted for 9 days for
further evaluation; Undergone X-ray & CT-scan on sept. 29, 2018 & was Dx c CVD infract c R
residuals & on e same day felt sudden weakness of L LE. Undergone another CT- scan to
check if clot was dissolved by e meds. given (name of medicines unrecalled) & was referred for
PTR p D/C in Vicente Sotto Memorial Medical Rehabilitation Center (VSMMRC). On Nov.7,
2018, pt. started PTR for Initial Pt Mx. & was referred to con’t PTR in San Nicolas Rehabilitation
Center (SNRC) due to its location & transportation problem of e pt. to con’t treatment in
VSMMRC. Started PTR on Dec.10, 2018 in SNRC & is currently taking PTR sessions.
Social Hx: Pt. lives c with his wife, 1 son & 1 daughter that helps him do almost all aspects of
ADLs like changing clothes, bathing & toileting; has no cultural & religious belief that can hinder
pt.’s PTR.
Employment status: Pt. was a warehouse worker in Mandaue City; works on his feet and
carries sacks of products ≈ 10 hrs. from mon. to sat.
Living Environment: Pt. lives in a bungalow house c cemented floor; has a stairs c 5 steps & s
railing upon entering main door; pt sleeps & stays in e living room ≈ 3 steps from main door;
living room↔C.R ≈ 4 steps; living room ↔ dining room ≈ 5 steps.
General Health Status: Pt. rates health status as fair, s any major life changes that occur from
last year prior to e incident.
Social Health Habits: States denies smoking & occasionally drinks alcoholic beverages.
Family Health Hx.
Mother Father Pt.
Cardiac problems. (-) (-) (-)
 HTN (+) (-) (+)
CA (-) (-) (-)
Arthritis (-) (-) (-)

Patient’s Medical/Surgical Hx: Pt. undergone an X-ray for work compliance (was unable to
recall the specific date.)
Medications:
Name Dosage Frequency Effect

Angiovastatin unrecalled q.d. during a.m. For lowering

the level
of cholesterol in
the blood by
reducing the
production of
cholesterol by
the liver.
Amlopdepine 10mg q.d. p dinner For lowering
Blood pressure,
prevent strokes
& heart attacks
.

Functional Status: Pt. is amb s AD but requires mod. → max. assist; is dependent in almost all
aspects of ADLs but is able to eat s assist.
Pt’s Goal: Pt. wants to be able to move L UE & amb s difficulty to be able independent
especially in ADLs & return to work to support family.
/O/:
OI: Pt. is a mesomorph; came to rehab amb s AD but requires mod. → max. assist +2 & (+)gait
deviation.
Cardiopulmonary System:
Atx Ptx Location /method
BP ( mmHg) 110/80 110/70 ® Brachial artery,
auscultatory,
sitting
PR (bpm) 82 97 ®Index finger,
pulse ox, sitting
SpO2 (%) 100 98 ®Index finger,
pulse ox, sitting
Integumentary system: Unimpaired
 Pliability/Texture: Unimpaired
Musculoskeletal system: Impaired
 Gross ROM: Impaired;L UE& LE
 Gross Symmetry: Impaired; L UE & LE
 Gross Strength: Impaired; L UE & LE
Neuromuscular system: Unimpaired
  Gait: Impaired; ↓ L arm swing; ↓ WB on L LE ; L foot drag
 Balance: Impaired ↓ standing, sitting & walking
 Locomotion: Impaired ; difficulty transferring from sit ↔ stand, requires min. Assist +1
Communication: Age- appropriate, (+) slurred speech.
Affect: impaired; behavioural is normal but pt. seldom shows signs of depression towards self
Cognition: Unimpaired, Pt. is oriented x3 as to person, place &time.
Learning barriers: Unimpaired, able to understand & comprehend simple instructions
Learning styles: Pt. learns best when demonstrated & visual presentation of e given exercise
to be conducted.
Educational needs:Pt needs proper education of proper positioning of L UE during siting,
proper sitting posture & positioning in bed to prevent complications that may lead postural
deviations.
TEST & MEASURES:
Sensory assessment: All exposed dermatome pattern were assessed & graded normal
except;
STD used: small nylon brush, sharp & dull ends of a reflex hammer
Legend:
Dermatome Light touch Pain Pressure
(L) (L) (L) 2- Normal
L4 2 1 2 1-Impaired
L5 2 1 2 0-Absent
S1 1 1 1
Sig: Pt. presence c impaired sensation as to light touch, pain & deep pressure on L S1 &
impaired as to pain on L L4 & L5 indicating UMNL 2° ® CVA.

DTR: R L
LEGEND:
++ ++
0-AREFELXIA
++ +++
++ ++ 1+ / + - HYPOREFLEXIA
++ +++ 2+/ ++ - NORMAL
++ + 3+/+++ - HYPEREFLEXIA

4+/++++ - CLONUS

Sig: Pt. is hyperreflexive towards L knee & L biceps reflex & is hyporeflexive towards L
ankle d/t UMNL 2°® CVA.
ROM: All major joints in the body were grossly assessed as to AROM & PROM & were
graded WNL & normal end-feel except :
Joints N⁰ AROM DIFF PROM DIFF END-FEEL
(L) shoulder flexion 0-180⁰ 0⁰ 180⁰ 0-180⁰ 0⁰ Firm

(L) shoulder abduction 0-180⁰ 0-40⁰ 150⁰ 155⁰ 25⁰ Empty

(L) shoulder external rot. 0-90⁰ 0⁰ 90⁰ 0-70⁰ 20⁰ Empty

(L) shoulder extension 0-60⁰ 0⁰ 0-60⁰ 0-60⁰ 0⁰ Firm

(L) Elbow flexion 0-150⁰ 0⁰ 150⁰ 0-150⁰ 0 Soft

(L) Elbow extension 150-0⁰ 0⁰ 150⁰ 150-0⁰ 0⁰ Hard

(L) Elbow Supination 0-90⁰ 0⁰ 90⁰ 0-90⁰ 0⁰ Firm

(L) Elbow Pronation 0-80⁰ 0⁰ 80⁰ 0-80⁰ 0⁰ Firm

(L) Wrist flexion 0-80⁰ 0⁰ 80⁰ 0-80⁰ 0⁰ Firm

(L) Wrist extension 0-70⁰ 0⁰ 70⁰ 0-70⁰ 0⁰ Firm

(L) Wrist radial dev. 0-20⁰ 0⁰ 20⁰ 0-20⁰ 0⁰ Firm

(L) Wrist ulnar dev, 0-30⁰ 0⁰ 30⁰ 0-30⁰ 0⁰ Firm

(L) Hip fexion 0-120⁰ 0-80⁰ 40⁰ 0-180⁰ 0⁰ Firm

(L) Hip abduction 0-40⁰ 0-30⁰ 10⁰ 0-40⁰ 0 Firm

(L) Hip External rot. 0-45⁰ 0-20⁰ 25⁰ 0-45⁰ 0 Firm

(L) Knee Flexion 0-150⁰ 0-45⁰ 105⁰ 0-150⁰ 0 Soft

(L) Ankle PF 0-50⁰ 0⁰ 50⁰ 0-50⁰ 0 Firm

(L)Ankle DF 0-20⁰ 0⁰ 20⁰ 0-20⁰ 0 Firm

Sig: Pt. presents c LOM towards L Shoulder abduction & external rotation d/t pain &
apprehension ; absence of AROM towards L Shoulder flexion, external rot., L Ankle DF
& PF & LOM towards all motions of L Elbow & Wrist d/t L hemiparesis 2 ®CVA.

MMT: All major muscle groups of the body were grossly assessed and graded 5/5
except for the ff.
Muscle groups Grade
(L) Shoulder Flexors 1/5
(L)Shoulder Abd. 2-/5
(L) Shoulder Extensors 0/5
(L)Shoulder External rot. 0/5
(L)Elbow Flexors 1/5
(L)Elbow Extensors 0/5
(L) Elbow Supinators &Pronators 0/5
(L)Wrist Flexors & Extensors 0/5
(L)Wrist Radial & Ulnar dev. 0/5
(L) Hip Flexors 3-/5
(L) Hip Abd. 3+/5
(L) Hip External rot. 2-/5
(L) Knee Flexors 2-/5
(L) Ankle PF& DF 0/5
Legend:
N 5 Full available ROM, against
gravity, strong manual resistance
Good 4 Full available ROM, against
gravity, moderate manual
resistance
Fair plus 3+ Full available ROM, against
gravity, slight manual resistance
Fair 3 Full available ROM, against
gravity, no resistance
Fair minus 3- At least 50% but not full ROM,
against gravity, no resistance
Poor 2 Full available ROM, gravity
minimized, no resistance
Poor minus 2– At least 50% but not full ROM,
gravity minimized, no resistance
Trace 1 No observable motion, palpable
muscle contraction, no resistance
Zero 0 No observable or palpable
muscle contraction
Sig: Pt. presents weakness in L shoulder flexors & abd.; L Elbow flexors, L Hip flexors, abd.&
external rot.;L Knee flexors & has no muscle tone on L Shoulder extensors, L Elbow extensors ,
pronators & supinators & in all motions of e L Wrist & L Ankle d/t L hemipariesis 2° ®CVA.
Balance and tolerance assessment:
BALANCE TOLERANCE
SIT 3 Good
STANDING 2 Poor +
 WALKING 1 Poor
Balance Grading:
4 Normal Pt. able to maintain steady balance s
support(static); Accepts maximal challenges,
shift weight easily c full range in all
directions(dynamic).
3 Good Pt. able to maintain balance s support, limited
postural sway(static); Accepts moderate
challenges, maintain balance while picking
objects off the floor(dynamic)
2 Fair Pt. able to maintain balance c handheld
support(static); May receive occasional
minimal assist (dynamic); Accept minimal
challenge, able to maintain balance while
turning head/trunk
1 Poor Pt. requires handhold et moderate to maximal
assist to maintain posture. Unable to accept
challenge

Tolerance Grading:
Poor: <15 min
Poor +: 15-30 min
Fair: 30-45 min
Fair +: 45-60 min
Good: >60 min
Sig: Pt. shows a ↓ B/T in ,sitting, standing & walking d/t muscle weakness, impaired motor
control & deconditioning 2° L Hemiparesis.
Functional Assessment:
ATDEP
Ambulation: Pt. can amb. s AD indep. but req. mod →max. assist., ↓ balance & tolerance in
walking. & standing.
Transfer: Pt. can transfer indep. From sit↔stand c min.assist & dependent in supine↔ sit.
Dressing: Pt. can dress B UE & LE indep but req. min. assist.
Eating: Pt can eat indep. Using R UE
Personal hygiene. Pt. is indep. But requires minimal assist +1 during toileting.
Postural Assessment :
Pt. is tested in sitting & standing position

Anterior Posterior Lateral

Head Eyes & ears Head is aligned c C7 Ear lobe is align
Symmetrical,ear lobes is spinous process; no acromion process. No
aligned c acromion.No lat.tilting noted deviatons noted
lat.bending noted
 Neck No tracheal deviation Occiput aligned c C7 No excessive cervical
noted. Neck is aligned c spinous lordosis noted
sternum. process
Shoulder Asymmeytical; L Asymmeytical; L Acromion process is
Shoulders slightly Shoulders slightly Align c ear lobe .
lower than R lower than R

Trunk/Spine chest & rib flares slight trunk No deviations noted.

greater @ e R side;(+) lateralization → (L)
slight trunk
lateralization → (L)

Pelvis/Hip (R) & (L) ASIS levelled (R) & (L) PSIS Normal pelvic tilt.
levelled
Knees (B) patella are aligned (B) Level popliteal No deviations noted
crease
Ankle No deviations noted No deviations noted Neutral

Foot/Toes 2nd DIP aligned c tibial No visible in/out No deviations noted

shaft toeing
Sig: Pt. has asymmetrical shoulders & Trunk deviation towards e L due to flaccidity of e L UE 2°
®CVA.

Gait assessment: Legend:

Stance Phase L R ↑ Increase
Heel strike ↓ N° ↓ Decrease
Foot flat ↓ N° N° Normal
Midstance ↓ ↑
Heel off ↓ N°
Toe off ↓ N°
Swing Phase
Initial swing ↑ N°
Mid swing ↓ N°
Terminal swing ↓ N°
Others ↓ N°
Sig: Pt shows no L arm swing, ↓ time spent on Midstance & WB of L LE, (+) L foot drag d/t
↓ muscle tone & ↑ L Hip flexion c circumduction of L LE in the swing phase d/t compensatory
actions 2° L Hemiparesis.
Special test
Special test (+) response Procedure Pt. response Significance
Babinski test Fanning of Stroke sole of Slight big toe ( + )UMNL
lateral toes & foot form heel to extension &
extension of big ball of toe fanning of lateral
toe toes
Oppenheim Fanning of Pressure along Extension of big (+)UMNL
lateral toes & the medial edge toe c slight
extension of big of the tibia fanning of lateral
toe toes.
Sig:Pt. has (+) Babinski & Oppenheim test indicating a (+) UMNL 2° ®CVA.
/A/:
Problem List:
1. LOM towards L UE & LE
2. Flaccidity of L UE & muscle weakness of L LE
3. ↓B/T in standing & walking
4. (+) gait deviation
5. Dependence most aspects of ADLs.
Therapy Dx:Pt has flaccidity of L UE; ↓ LOM & weakness of L UE&LE resulting to (+) gait
deviations , ↓ B/T in standing & walking leading to dependence of most aspects of ADLs.Pt may
benefit from PROME to maintain joint integrity, ES on L UE & LE flexors & extensors
formuscle re-education, gait training c visual feedback to improve ability to amb. & prevent
postural deviaton, II bar exercises to ↑ B/T & LE strength.
Practice pattern: Neuromuscular Pattern D:Impaired motor function &sensory integrity
associated c non-progressive disorders of the Central Nervous System acquired form
Adolescence or Adulthood.
Prognosis: Pt. has a good rehab potential since pt.’s case is still in e golden period of recovery
in CVA, eager & willing to participate & has a good support system despite having difficulty
performing e given exercises.
/P/:
LTG:
1. Pt. will be able to regain a near functional ROM on L UE& LE p 3 mos. of PTR to
improve ability in performing ADLs. & amb. c less difficulty.
2. Pt will be able to demonstrate an ↑ in muscle tone of e L UE & muscle strength on L LE
to a grading of 3/5 & 4/5 p 4 mos. of PTR to become indep in some aspects of ADLs.,
improve ability to transfer & amb. & to correct e postural deviaton.
3. Pt. will improve indep. towards ambulation p 4 mos of PTR to become more functional &
be able to amb. in crowded areas c less difficulty.
4. Pt will ↑ B/T towards walking & standing to a good grade p 4 mos of PTR to improve
pt.’s amb. & become more active, & in preparation for progression of exercises
.
STG
1. Pt. will demonstrate an ↑ ROM c increments of 5° on all motions of AROM & PROM p 2
mos. of PTR to gradually become indep. in some aspects of ADLs, amb. c less difficulty
& in preparation for e progression of Mx given..
2. Pt. will show an ↑ mmt grade from 0/5→1/5, 1/5 → 2-/5 ,2-/5→3/5 & 3/5 to 3+/5 in L Hip
flexors p 18 Rx sessions to be able to initate indep towards some aspects of ADLs,
become more active & for e progression of e Mx given.
3. Pt. will show an ↑ in muscle tone of L UE p 2 mos of PTR to ↑ activity using L UE,
prevent postural deviations & ↑ indep towards ADLs.
4. Pt will demonstrate a ↑ Balance towards walking from poor → fair, in standing from fair→
good & ↑ tolerance in both to a good grade p 3 mos of PTR to improve pt.’s amb. &
become more active, & in preparation for progression of exercises.
IPT Management:

1. ES on L UE flexors, extensors, Upper trapezius; L ankle PF & DF x 10 mins for muscle

re-education.
2. ES motorpoint in e palmar & dorsum of L hand x 30contractions x 2 sets.
3. PROMEs on L UE & AAROMEs on L LE to maintain in D1 & D2 PNF pattern to maintain
available ROM.
4. PREs on R UE c 2lb DB & R LE c 2lb AW to maintain available muscle.
 5. // Bars exercise to ↑ B/T ,amb. & LE strength & muscle endurance.
a. Marching on seat x 10 reps.
b. Heel & toe rise on L LE seat 6SH x 10 reps.
c. Sit to stand x 10 reps.
d. Mini squats x 10SH x 5 reps.
e. Lunges x 10SH x 5 reps.
f. Weight shifting x10SH x10 reps.
g. Pawing on L LE x 10 reps.
h. Gait training c yellow/tan theraband & c visual cues x 3 rounds.
6. Ergobike c 3 speed x 10 mins to ↑ cardiopulmonary endurance & joint integrity.
HEP:
1. Self PROME of L UE in AP c 10 reps.
2. Muscle setting on L UE c 6SH x 10 reps.
3. Heel & toe rise on seat x 10 reps.
Recommendation:
1. Bandaging using DF assist. in L LE during amb. to avoid drag.
Precautions:
1. Falls
2. Fatigue

Rene Sandlee Orate

PT intern 2019