Initial Evaluation

NAME: Babatuan , Samuel DATE OF I.E: December 8,2018

SEX: ♂ DATE OF Adm: Unrecalled
ADDRESS:Alaska, Mambaling ,Cebu City DATE OF REFERRAL: December 5,2018
DOB: January 5,1964 DATE OF REFERRAL: December 5,2018
CONTACT NO: REFERRING MD: Unrecalled
NATIONALITY: Filipino PHYSIATRIST: Dr.Villar
RELIGION: Roman Catholic Dx: ® CVA
CIVIL STATUS: Single Meds: Amlodepine 10 mg; Angiotat 40 mg; Both
OCCUPATION: Construction Worker taken 3x/day p meals.
HANDEDNESS: ®
/S/:All information was taken from the pt.
C/C:Pt. c/o difficulty extending L UE &also complains L LE weakeness & stated he has difficulty
performing ADL’s like changing clothes, cooking food & toileting.
HPI:Pt. condition started last May 21,2017 when he suddenly felt weakness on L UE & began
having difficulty speaking ; was rushed by his brother @ Cebu City Medical Center,& was admitted
for 9 days for further evaluation; undergone CT-scan & was Dx c ® CVA ; was referred for PTRe
day after d/c.Started PTR @ Vicente Sotto Memorial Medical Rehabilitation Center on june 2017
until November 2018 where he progressed from being W/C bound to amb. s AD; was endorsed
to San Nicolas Rehabilitation Center for PTR on December 5,2018 & is currently talking PTR
session.
Social Hx:Pt. lives c his 1 elder brother & mother that do his ADLs like laundries, cleaning e
house & helps him in cooking food, &changing clothes; has no cultural & religious belief that can
hinder pt’s PTR.
Employment status: Pt. was a construction worker; works on his feet from ≈ 8 hrs. from mon
to sat.
Living Environment: Pt. lives in a 2 storey house ;cemented; tiled floors ;(+) stairs c railing on
e side & 6 steps going up; main gate ↔ main door ≈ 7 steps; main door ↔ pt. room ≈ 6 steps;
pt. room ↔ C.R ≈ 10 steps.
General Health Status: Pt. rates health status as good s any major life changes that occur from
e past yr. of 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

Angiostat 40 mg 3x /day p meals To prevent

chest pain
Amlopdepine 10mg 3x/day p meals For lowering
Blood
pressure,
prevent
strokes &
heart attacks .

Functional Status: Pt. is amb. s AD & transferring from sit ↔ stand, has difficulty performing
ADLs like bathing,eating & toileting but is able to complete task s assist.
Pt’s Goal:Pt. aims to ↑ independence on ADL’s like cooking food ,amb s difficulty & able to
return to his work as a construction worker.
/O/:
OI:Pt is ectomorphic, came to rehab amb s AD, (+) gait & postural deviation.
Cardiopulmonary System:
Atx Ptx Location /method
BP ( mmHg) 130/80 130/80 ® Brachial artery,
auscultatory,
sitting
PR (bpm) 107 106 ®Index finger,
pulse ox, sitting
SpO2 (%) 99 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
 Balance: Impaired ↓ standing
 Locomotion: Impaired ; difficulty transferring from sit ↔ stand, requires min. assist +1.
 Motor function:Impaired
Communication: Age- appropriate, (+) slurred speech
Affect:Unimpaired; behavioural & emotional responses are normal
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 posture during sitting to prevent
complications.
TEST & MEASURES:
Sensory assessment: All exposed dermatome pattern were assessed & graded normal
STD used: small nylon brush, sharp & dull ends of a reflex hammer

LEGEND:
2-Normal
1-Impaired
0-Absent

Significance: Pt’s sensation is 100% intact sensation on pain,deep pressure & light touch.
DTR:
L R

LEGEND:

0-AREFELXIA

1+ / + - HYPOREFLEXIA

2+/ ++ - NORMAL

3+/+++ - HYPEREFLEXIA

4+/++++ - CLONUS

Sig:Pt. has hyperreflexia on L triceps & patellar tendon & hyporeflexia on L brachioradialis &

biceps indicating an UMNL d/t ® CVA .

ROM:All major joints of the body were grossly actively and passively WNL except the ff:

N° AROM DIFF PROM DIFF End-

Feel
L 0-180° 0-50°° 130 0-150° 30° Empty
shoulder
flexion
L 0-60° 0-25° 35° 0-60° 0° Firm
Shoulder
extension
 L 0-180° 0-20° 160° 0-80° 100° Empty
shoulder
abduction
L 0-90° 0-16° 74° 0-30° 60° Empty
shoulder
External
rot.
L 0-70° 0-16° 54° 0-70° 0° Firm
shoulder
Internal
rot.
L Elbow 0-150° 30-130° 20° 30-140° 10° Soft
flexion
L Elbow 150-0° 130-30° 20° 140-30° 10° Hard
extension
L wrist 0-80° 0° 80° 0-58° 22° Firm
flexion
L wrist 0-70° 0° 70° 0-40° 30° Firm
Extension
L Hip 0-40° 0-20° 20° 0-30° 10° Firm
abduction

L Hip 0-120° 0-40° 80° 0-110° 10° Firm

Flexion
L Knee 0-135° 0-120° 15° 0-135° 0° Firm
Flexion
L Ankle 0-50° 0-10° 40° 0-20° 30° Firm
PF
L Ankle 0-20° 0-5° 15° 0-20° 0° Firm
DF
Sig:Pt. presents c LOM towards all L Shoulder motions due to spasticity; LOM towards shoulder
flexion,abduction & external rotation due to pain & LOM towards L LE motions due to muscle
tightness 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 2-/5

L shoulder Extensors 2-/5

L shoulder Abductors 2-/5

L shoulder External 2-/5

Rotators
L shoulder Internal 2-/5
Rotators
 L Elbow Flexors 2/5

L Elbow Extensors 2-/5

L Wrist Flexors 1/5

L Wrist Extensors 1/5

L Hip Flexors 2-/5

L Hip abductors 3/5

L Knee flexors 3-/5

L Ankle PF 2/5

L Ankle DF 2-/5

Legend:

N 5 Full available ROM, against

gravity, strong manual
resistance
Good 4 Full available ROM, against
gravity, moderate manual
resistance
Fair 3+ Full available ROM, against
Plus gravity, slight manual
resistance
Fair 3 Full available ROM, against
gravity, no resistance
Fair 3- At least 50% ,but not full
minus ROM,against gravity ,no
resistance
Poor 2 Full available ROM, gravity
minimized, no resistance
Poor 2– At least 50% but not full ROM,
minus gravity minimized, no
resistance
Trace 1 No observable motion,
palpable muscle contraction,
no resistance
Zero 0 No observable or palpable
muscle contraction
Sig:Pt. has weakness of L shoulder flexors, extensors, abductors, external rotators * internal
rotators; of L elbow flexors & extensors; of L hip flexors, abductors & L knee flexors; of L ankle
plantarflexors & dorsiflexors d/t disuse 2° ® CVA.
Modified Ashworth Scale
Area Grading
L wrist ext . 3
 L wrist flex. 1
L elbow flex 1
L elbow ext. 3
L knee flex. 1+
L Knee ext. 1

Legend:
0 = Normal tone, no increase in tone
1 = Slight increase in muscle tone, manifested by a catch and release or minimal resistance at
the end of the range of motion when the affected part (s) is moved in flexion and extension.
1+ = Slight increase in muscle tone, manifested by a by a catch and release or minimal resistance
throughout the remainder (less than half) of range of motion when the affected part (s) is moved
in flexion and extension.
2 = More marked increase in muscle tone through most of the range of motion but affected part(s)
easily moved
3 = considerable increase in muscle tone, passive movement is difficult.
4 = Affected parts(s) rigid in flexion and extension.
Sig: Pt has ↑ flexor spasticity on L wrist extension & L elbow extension & an ↑ extensor spasticty
on L knee flexion d/t UMNL 2° ® CVA.
Functional Assessment:
ATDEP
Ambulation: Pt. can amb. s AD indep. but c ↓ balance & tolerance in walking.
Transfer: Pt. can transfer indep. From sit↔stand; supine↔ sit.
Dressing: Pt. can dress B UE & LE indep. but has difficulty. During dressing LE
Eating: Pt can eat indep. Using R UE
Personal hygiene. Pt. is indep. But requires minimal assist +1 during toileting.
Sig: pt is indep. on his ADLS although requires min assist on toileting & presents difficulty
performing ADLs.
Balance and tolerance assessment:
BALANCE TOLERANCE
SIT 4 Good
STANDING 3 Fair+
WALKING 3 Fair
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 good balance in standing, walking & tolerance in walking.

Postural Assessment :
Pt. is tested in sitting & standing position

Anterior Posterior Lateral

Head Head slightly tiled Head slightly tiled Ear is ant. c humeral
towards (L) towards (L) side head
side,
Neck No tracheal deviation Occiput aligned c C7 No excessive cervical
noted. Neck is aligned spinous process lordosis noted
c sternum.
Shoulder (L) acromion is slightly (L) shoulder blades is Slightly protracted
lower on (R) slightly shoulders
acromion lowerthan (R)
shoulder blades
Trunk/Spine chest & rib flares Aligned thoracic – (+) slight inc.kyphosis of
evenly lumbar thoracic spine
vertebrae
Pelvis/Hip (R) & (L) ASIS levelled (R) & (L) PSIS levelled (+) post pelvic tilt

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 toeing No deviations noted
shaft
Sig: Pt. has (+) kyphotic posture c slight trunk lateral deviation towards e R d/t compensatory
action & possible muscle tightness resulting from hemiparesis & muscle weakness 2° ® CVA.
Gait assessment:
Stance Phase L R
Heel strike ↑ N°
Foot flat N° N°
Midstance ↓ ↑
Heel off ↑ N°
Toe off ↓ N°
Swing Phase
 Initial swing ↑ ↓
Mid swing ↑ ↓
Terminal swing ↑ ↓
Others ↓ ↑

Legend
↑ - Increase
↓ - Decrease
N°- Normal
Sig: Pt. shows an ↑ in R arm swing during swing phase of L LE & ↑ L Hip flexion c
circumduction during swing phase of L LE to compensate extensor spasticity of L LE & muscle
weakness, ↓ time spent in midstance & WB of L LE & also absence of L arm swing d/t flexor
spasticity & possible muscle tightness 2°L Hemiplegia.
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
Appley’s scratch Pt. is unable to Pt. is asked to Pt. is unable to (+)Frozen
complete place the arm reach his back & Shoulder
movement due overhead, then reach upward.
to pain & LOM reach behind the
neck to touch
his/her back Pt.
is then asked to
place the hand
on the lower
back and reach
upward as far as
possible
Sig: Pt has a (+) response on Babinski test indicating a damage on e corticospinal tract
& has a (+) Appley’s scratch test d/t muscle tightness 2° ® CVA.
/A/:
Problem List:

1. LOM towards L UE&LE motions

2. (+) spasticity & muscle tightness on L UE&LE
3. weakness on L UE&LE muscles
4. ↓B/T in standing & walking
5. (+) gait deviation
6. (+) postural deviation
7. Dependence on some aspects of ADLs
Therapy Dx. Pt has LOM, weakness & spasticity of L UE&LE resulting to gait, postural
deviations & ↓ B/T leading to dependence of some aspects of ADLs. Pt. may benefit from
AROME to maintain joint integrity, PNF stretching techniques to ↑ ROM & ↓ muscle tightness,
PREs to ↑ muscle strength, gait training c visual feedback to improve ability to amb. & improve
posture, 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 fair rehab potential. Pt. listens attentively, is willing to learn & do the proper
procedures in performing e given exercises.
/P/:
LTG:

1. Pt. will be able to regain near full ROM on L UE/LE p 3 mos. of PTR to ↑ Pt. independence
towards ADLs & amb. c less difficulty.
2. Pt. will be able to demonstrate an ↑ muscle strength on to a grading of 3+/5 on both L
UE&LE p 4 mos of PTR to ↑ Pt. independence in performing ADLs, become more active,
↑ B/T in standing & improve gait.
3. Pt will demonstrate improvements in amb. p 5 mos of PTR to be able to walk s less
difficulty & impove ambulating in crowded areas.
4. Pt. improve posture p 4 mos of PTR to avoid further exacerbation of complications & to be
able to perform activities s less difficulty.

STG:

1. Pt will demonstrate an ↑ ROM c increments of 5° on all motions for both PROM & AROM
p 1 mos of PTR to improve pt.’s performance on Mx given, ADLs & amb.
2. Pt will show an ↑ mmt grade from 1/5 → 2-/5, 2-/5 →2/5, 2/5 →3-/5 , 3-/5 → 3/5 & 3/5 →
4/5 p 18 Rx sessions in preparation for progression of Mx & ↑ performance on ADLs &
amb.
3. Pt will show a ↓ on gait deviations p 3 mos. of PTR to improve amb. & in preparation for
progression of Mx.
4. Pt will show a ↓ postural deviations p 2 mos of PTR to prevent further complications &
prevent compensatory motions upon performing e given exercises.
IPT Management:
1.ES on L UE flexors & extensors x 10 mins for muscle re-education.
2. AAROMEs on L UE in AP, L Knee towards flexion & L Ankle in AP c 6SH @limits of pain
to ↑ ROM.
3 .PNF stretching hold-relax c 6SH x 3 reps x3 sets @ limits of pain on D1, D2 flexion &
Extension of e L UE to ↑ ROM.
4.GPS of L sternocleidomastoid & scalene; L Knee flexors; L elbow &wrist flexors c 30SH x3 sets
to ↓ spasticity & muscle tightness & improve. ROM
5. Isometric exercises on L UE& LE in PNF patterns D1 extension & D2 flexion x 10 reps
to ↑ muscle strength.
6.PREs on R UE using 2 lbs dumbbell & 3 lbs Ankle weights in AP to maintain muscle
strength on R extremities.
7.II bar exercises c visual cues to prevent compensatory actions ↑ L LE strength, B/T in standing,
& improve posture.
a.Mini squats c 10SH x 10 reps
b.High knees x 10 reps
c.Single leg on L LE stance 10SH x10 reps
d. Pawing on L LE x10 reps
8.Stairs climbing exercise x 3 rounds to ↑ LE strength to improve amb .
9. Gait training c cones x 3 rounds ↑ LE strength to improve amb.
HEP:
1. Self-stretching on L Wrist flexors c 30SH x 3 sets to ↓ muscle tightness
2. Step up exercise on stair steps x12 reps x3 sets to ↑ LE muscle strength
Recommendations:
1. ES motor points @ L dorsum& palmar of hand x 30 contractions x 3 sets for muscle re
education
Precautions:
1. Falls
2. Vital signs
3. Fatigue

Rene Sandlee Orate

PT intern 2019