PT Initial Evaluation for MS.docx

Initial Evaluation General Information Patient’s Name Sex Age Civil Status Address Occupation Referring Unit Referring Doctor Rehab Doctor Date of referral Date of Consultation Date of IE Diagnosis

: RMG : Female : 30 y/o : Married : Los Angeles, California : Nurse : General Neurology : Dr. Charles Monroe : Dr. Anthony Adams : June 13, 2013 : June 13, 2013 : June 15, 2013 : MS with laboratory support

Birthdate Handedness Nationality

: May 2, 1983 : (R) : American

Present condition started 6 months PTC when she noticed an onset of weakness in her (L) arm which was followed by subsequent numbness descending down to the (L) leg. She was able to walk normally but a few weeks later developed tingling sensation and tight band like sensation on both LE, loss of balance, and scanning speech. Pt was confined the same day and undergone laboratory examinations such as LP which revealed elevated IgG in spinal fluid, MRI that showed acute and chronic lesions in the brain and spinal cord. Neurologic examination showed optic neuritis on the (L) eye and nystagmus on the (L) lateral gaze.

HPI:

Family physician treated her with I. V. Solumedrol c excellent benefit, and the pt became ambulatory after 2 wks. A wk ago the pt had a dramatic neurologic decline during which she was initially unable to sit up, lost strength and sensation in her LE. Patient's family reports that she had a lot of difficulty c mood control, particularly excessive crying and laughing. She was also given oral prednisone 20 mg po qid, Maalox 1o cc po qid, Valium c very modest benefits. Pt was discharged and was referred to PT for further eval and tx. (-) HPN (-) DM FHx: (+) HPN on both sides SHx: Has an active lifestyle and a nurse for the last 10 years; lives c husband and daughter in a 2-storey house. PMHx:

c/o: weakness on both LE and (L) UE Easy fatigability V.S BP: a-120/80 mmHg d- 130/80 O: HR: 78 bpm RR: 16 cpm Temp: afebrile to touch OI: amb c quad cane A/C/C Ectomorph S:

p-130/80

Palp: Normotonic in both UE and LE ROM: All jts of both UE and LE are WNL on all planes of motion e xcept from the ff: Difference Active 30

Cervical 

°

(L) shoulder

120

(L) hip

80

(R) hip

90

(L) knee

100

(R) knee

100

°

Passive -

Normal 45

Active

°

180

°

180

°

60

°

0

°

°

120

°

120

°

40

°

0

°

°

120°

120°

30

°

0

°

°

120°

120°

20

°

0

°

°

120°

120°

20

°

0

°

°

Sig. LOM on AROM 2 to pain and mm weakness MMT: All mm of the UE and LE are grossly graded 5/5 except for the ff: (L) shoulder flexor 3/5 (L) hip flexor 3/5 (R) hip flexor 3/5 (L) knee flexor 4/5 (R) knee flexor 4/5 Sig. mm weakness 2 to pain and inactivity °

Sensory Assessment: STD: 100% sensory innervation intact Deep sensation: (+) proprioception in all body parts DTR’s: biceps ++ triceps++ patella +++

Pathologic Reflexes: (+) Babinski (R) (+) Chaddock (R) (-) Hoffmann Special Test: (+) Dix Hallpike (+) Caloric Test (+) Rhomberg ADL Analysis: Eating: FIM 4 Grooming: FIM 4 Bathing: FIM 3 Dressing: FIM 4 Toileting: FIM 3

Passive

(+) kinesthesia on all 4’s

Bladder management: FIM 5 Bowel management: 4 Transfer: bed, chair, w/c FIM 4 Locomotion: walking FIM 3 Locomotion: stairs FIM 2 Communication: expression FIM 5 Communication: comprehension FIM 6 Social interaction: FIM 6 Problem solving: FIM 5 Memory: FIM 5 A:

Problem list 1. (L) UE, both LE weakness 2. Mm weakness toward shoulder, hip, and knee  3. ADL’s c min to max assistance as to bathing, toileting, and locomotion and transfer

P:

STG: To be achieved up to 3 mo 1. Increase or maintain ROM in all jt 2. Improve sensory feedback 3. Improve mm strength 4. Improve motor control 5. Improve coordination 6. Improve function in ADL LTG: to be achieved more than 3 mo. 1. Prevent or retard the development of secondary complications 2. Maintain general health condition of the patient 3. Attain highest functional level of the patient Mx: Pt is to be treated t.i.w as out patient c the ff PT Mx: 1. Cryotheraphy x 15 min (L) shoulder, both LE 2. TENS x 15 min (L) shoulder both LE 3. US x 1.5 w/cm2 x 5 min (L) shoulder 4. AROM on all jt at all planes 5. Stretching x 15s x 4 reps (L) shoulder, both LE 6. Gentle massage surrounding jt 7. Finger ladder (11-15 steps) x 10s x 4 reps 8. Arm Ergo x 5 min, Leg Ergo x 10 min 9. PRE’s x 2 lbs x 10 reps both UE, PRE’s x 5 lbs x 10 reps both LE 10. Codmann’s ex 11. Frenkel’s ex 12. Gait Training a. // bars b. Quad cane c. Stair climbing 13. HEP