GUANELLA CENTER INC.

PHYSICAL THERAPY SERVICES

IPT
(MARCH 12, 2020)

Pt’s Name: Mia, Arrean Rustin

Age: 17y/o
Sex: Male
Address: #15A Manuela St. Brgy. Pasong Tamo , Philand , Quezon City.
Dx: Global Developmental Delay (GDD), c Hx of Seizures, c Hx of Distal Femur Fx.

S:
C/c: (Informant): Pt’s mother c/o pt’s intermittent localized dull aching pain on ® knee by exhibiting
limping gait.
Rehab Goal: To decreased pain on (R) knee.
O:
VS:
Before After
PR 82 bpm 94 bpm
RR 20 cpm 22 cpm
Temperature 36.2ºC 36.2ºC
Findings: Pt’s VS are WNL.
Significance: For baseline & precautionary purposes

OI:
 w/c bound
 Normocephalic
 P/N
 (+) gait deviation (see gait analysis)
 (+) postural deviation (see postural analysis)
 (-) eye deformity
 (-) drooling
 (-) cortical thumb
 (-) facial assymetry
 (-) atrophy
Behavior
 Response to play
 Uncooperative most of the time but pt’s was being cooperative when telling him a story and
singing nursery rhyme.
 short attention span ~3mins
Palpation
Normothermic in all exposed body parts
Normotonic on (B) UE and LE
 (-) tenderness
ROM: all major joint on (B) UE, LE, and spine are actively and passively assessed and WNL c normal
endfeel except:
MOTION NORMAL AROM PROM DIFFERENCE END FEEL
From Normal
Value
A P
(R) knee flexion 0°-135° 0°-70° 0°-100° 0°-65° 0°-35° Empty
(R) knee extension 135°-0° 135°-30° 135°-20° 135°-30° 135°-20° Empty
Findings: Pt. has LOM on (R) Knee flexion and extension due to history of fx on (R) distal femur that
has Intermittent localized dull aching pain so that pt. intentionally contracting his ® knee towards flexion
Significance: Pt. will have moderate difficulty in ambulation.

FMT:
Findings: Pt. was able to grasp objects, clap, raise hands, kick the ball, and turn around the bed.
Significance: to test muscle capacity and strength
 GUANELLA CENTER INC.
PHYSICAL THERAPY SERVICES
IPT
(MARCH 12, 2020)

Postural Analysis
(/) standing position

Ant. Lat. Post.

Head Slightly forward head Slightly Forward head Slightly Forward head

Shoulder (B) slightly protracted (B) slightly protracted (B) slightly protracted
Scapula N/A (B) slightly protracted (B) slightly protracted
Spine N/A Slightly emphasized Slightly emphasized
thoracic Kyphosis thoracic Kyphosis

Pelvis (L) slightly higher than (L) slightly higher than (L) slightly higher than
(R) (R) (R)
Hip (L) slightly higher than (L) slightly higher than (L) slightly higher than
(R) (R) (R)
Knee (B) slightly facing (B) slightly facing (B) slightly facing
outward outward outward
Ankle (B) slightly facing (B) slightly facing (B) slightly facing
outward outward outward
Findings: Pt has fair body posture due to pt’s only did PWB on (B) LE because of hx of fx on ® distal
femur that causes the (L) LE to mimic the posture.
Significance: Pt. should focus on strengthening of (B) LE to improve proper body posture.

Gait Analysis
R L
Stance Phase
- Heel strike Absent Neutral
- Foot Flat Absent Neutral
- Midstance Absent Neutral
- Heel-off ↑ Neutral
- Toe-off ↓ Neutral
Swing Phase
- Pre-swing ↓ Neutral
- Midswing ↓ Neutral
- Terminal Swing ↓ Neutral
Step Length ↓ ↓
Stride Length ↓ ↓
Lat. Pelvic Shift ↓ ↓
Pelvic Rotation ↓ ↓
Arm swing ↓ ↓
Significance: Pt. may focus treatment in strengthening of (B) LE to improve ambulation.

Functional Assessment
 Pt. has good sitting balance and tolerance while Pt. has fair standing balance and tolerance. Pt.
able to maintain balance c handheld support may require occasional minimal assistance and pt.
accepts minimal challenge in standing.

ADL Assessment:
 Pt has moderate difficulty in ADL’s as to self-care, transfers, and ambulation due to global
developmental delay.

A:
PT Impression: Pt was medically diagnosed with Global Developmental Delay (GDD), c Hx of
Seizures, c Hx of Distal Femur Fx. further defined with short attention span, uncooperative but can
 GUANELLA CENTER INC.
PHYSICAL THERAPY SERVICES
IPT
(MARCH 12, 2020)

response to play. Pt had moderate difficulty in ADL’s as to self-care, transfers, bed mobility, and
ambulation.

Rehab Potential: Pt has fair rehab potential d/t pt’s global developmental delay as self-care, transfers,
bed mobility, and ambulation and Hx of distal fx on ® femur.

Problem List:
1. Intermittent localized dull aching pain on (R) knee
2. Intentional contraction (R) knee towards flexion due to hx of fx on (R) distal femur.
3. Postural Deviations
4. Gait Deviations
5. Short attention span ~3mins.
6. Moderate difficulty in ADL’s as to self-care, transfers, and ambulation.

LTG:
Participative:
Pt. continues to undergo Physical Therapy session for pt’s physical and functional improvement.
Preventive:
Pt’s family will prevent further injury on (R) knee and other co morbidity factors such as muscle
tightness.
Rehabilitative:
For the pt to be able to have pain free on (R) knee; improve muscle strength on (B) LE; Improve
standing balance and tolerance and to do ADL’s c minimal assistance as to self-care, transfers, bed
mobility, and ambulation.

STG:
1. To increase attention span during the therapy.
2. To decrease intentional contraction of (R) knee towards flexion.
3. To be able to improve proper body posture.
4. To be able to demonstrate improvement in ADL’s as to self-care, transfers, and ambulation.
P:
PTMX
1. ES on (B) quads x 10 minutes
2. GPS on (B) hamstring and gastrocnemius x 10 sh and 10 reps x 1 set.
3. Slow PROMES of (B) LE towards AP x 10 reps x 1 set.
4. Strengthening exercise of quads (sitting position)
a. Ball kicking c FES on (B) quads and TA’s x 10 minutes.

Suggested PTMX
1. Bike ergo x 3 minutes

Prepared By: Noted By:

KYLE PAOLO E. DULAY

DCSLC PT INTERN 2020 VILMA A. RAMOS, PTRP
PT SUPERVISOR