Reference no: EM133325441

Case: The following is a full-length physical therapy evaluation for which you are to report Dr. Barneswell's service. This is not a consultation, but a physical therapy evaluation. A Z code for the physical therapy is reported as the first-listed diagnosis, because that is the primary reason the patient is being evaluated. Next listed would be the quadriplegia.

LOCATION: Outpatient, Clinic

PATIENT: Terra Benson

REFERRING PHYSICIAN: Ronald Green, MD

PHYSICIAN: Mary Barneswell, MD

DIAGNOSIS: Congenital cerebral palsy spastic quadriplegia with intrathecal baclofen pump.

SUBJECTIVE: Terra is referred to Physical Therapy for evaluation for a session of intensive summer programming. The patient has participated in the summer programming in the past, and both the patient and her mother state that she has benefited from this programming, particularly in the area of balance. Terra states that at the time of her first summer session she was unable to sit independently on the toilet, and following the summer session, she has been able to sit independently on the toilet. The patient states that she uses both a power and manual wheelchair for transportation. Her mother states that they switch on and off which one they use. Her mother is with her quite a bit of the time to assist her with activities. The patient is a 10th grader this year at Mother of Hope School. The patient states that she is not receiving any physical therapy programming at school. They are also not performing any type of home exercise program at this time. Both the patient and her mother state that both sitting balance and tightness of the adductor musculature are their primary concerns at this time. Patient/Family goal: Both the patient and her mother state that they would like to increase Terra's sitting balance.

OBJECTIVE: Observation: Terra does demonstrate a windswept posture to the right, indicating weakness of the left gluteal musculature compared to the right.

Range of Motion: Ankle dorsiflexion on the left is to the neutral position. The patient does report that she did have an injury to that leg a few weeks ago, which may be causing some decrease in the range of motion. On the right, ankle dorsiflexion is to 10 degrees. Straight leg raise bilaterally is 90 degrees. Internal and external rotation of the hips is within normal limits bilaterally. Abduction bilaterally is to 30 degrees passively.

Manual Muscle Testing: Strength of the lower extremities, including hip flexion, knee extension, and knee flexion, is 2/5; the patient is not able to move her extremity through the full range of motion. Hip flexion on the right is at 1/5; the patient does elicit a muscle contraction but is not able to move the lower extremity against gravity.

Mobility: The patient transfers from her wheelchair to a mat with maximal assistance of her mother. It has been noted in the past that the patient was able to transfer from the wheelchair to the mat; however, she did require maximal assistance on this date. The patient is able to roll from supine to side-lying with minimal assistance. She transitions from a supine to sitting position with maximal assistance. She also transitions from sitting to standing with maximal assistance and with maximal assistance to remain standing.

Balance: The patient's balance was tested in a seated position. In short sitting, the patient is able to resist balance disturbances; however, she has some difficulty when trying to balance without the use of upper extremities for support. The patient particularly struggles with balance if an anterior balance disturbance is given. In long sitting, the patient is able to maintain the long-sit position with use of upper extremities for supports.

ASSESSMENT: The patient presents to physical therapy with decreased balance reactions, some decrease in range of motion of the lower extremities, and decrease in pelvic stabilization musculature, particularly on the left side. I believe this patient would benefit from a physical therapy program to adjust these issues. Goals for this patient include (1) that the patient's passive hip abduction will increase by 5 degrees for increased motion for daily activities; (2) that the patient will be able to maintain balance on a dynamic surface times 10 seconds without the use of upper extremities for increased balance; (3) that the patient's pelvic stability will be increased through activity such as tall kneeling and bridges, which will also help to improve her balance reaction; (4) that the patient will reach for rings while maintaining balance on a dynamic surface successfully on 8/10 trials.

PLAN: We will plan to see this patient two times a week for the summer programming utilization at dynamic surface to help encourage balance reactions. The patient may also be progressed into a home-exercise program for increased strengthening of the pelvic stabilizers. Thank you for this referral.