with Conrad de Jesus

SUBJECTIVE: Parents main concern is Crystal's functional mobility.

Range of Motion:
within normal range on both legs and arms. (active-assistive)
Muscle strength: both arms and legs can move against gravity less than 50% of the available range. (2+/5)
Hips: Hips are poor-fair. Note: hip internal rotation, flexion and adduction are contraindicated when combine due to hips subluxation. (Barlow's test-is positive due to dislocatable hips.) Shoulder Joints stability is fair, no sign of subluxation.
Deep Tendon Reflex: hyporeflexia to areflexia (slow reacting muscle response.)
Developmental Reflex: slow anti gravity muscle response.
Posture: increase on lordotic curve both on cervical and lumbar area. S-curve scoliosis upon standing due to muscle imbalance.
Cubitus valgus is also present on her elbow. Both Wrist joints are ulnarly deviated. Forearm pronated with mild contracture of the supinator muscles.
Balance: good-fair upon sitting. fair upon static standing, standing with support
Gross Motor: She is able to walk with two hand trunk support. She is able to tolerate standing holding thru furniture, she able to sit independently. However, she is unable to sit from supine. She an walk independently, pull up and raise her head and upper trunk, pedal her legs well, during pool therapy with water on her midthorax level.

ASSESSMENT: She able to tolerate all Physical Therapy exercises, stretching, Range of Motion with quick stretch technique to stimulate muscle contraction.

Desire outcome/Prognosis:
1. Improve motor control of stability and movements patterns.
2. Caregiver will be able to follow the home exercise program independently.

1. Will be able to improve balance upon standing and tolerate standing activities well without knees hyperextension.
2. Will be able to respond well upon muscle stimulation.
3. To correct posture and prevent/delay its progress.
4. To increase functional mobility.
5. Will walk independently on a pool without loosing her balance.
6. Will be able to control her self well upon floating.

PLAN: Continue skilled P.T. for neurodevelopmental techniques incorporate with play therapy, therapeutic exercise/activities, therapeutic massage, stretching, gait training, pool therapy and caregiver education for 60 minutes for twice a week.

Early Intervention Specialist


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