MDC Hydrocephalic Contraindications and Plan of Care Based on Physical Therapy PPT

ROMY’S WORLD PPECPediatric speech, occupational, physical,
nursing, and behavior therapy services
1021 SW 67 Ave Miami Fl. 33155 786-953-7111
Romy’s World PPEC (romysworldppec.com)
INFO@ROMYSWORLDPPEC.COM
info@kidstherapyconnection.com
Physical Therapy Evaluation Report
Name:
Ryan Calderon
Date of Evaluation:
4/12/2022
Date of Birth:
12/18/2020
G91.8 Hydrocephalus
Age:
15 months
Diagnosis:
Secondary
Diagnosis:
Evaluation:
Initial evaluation
Therapist:
Maria D.Machado DPT
Medical/Social/Schoo
l History:
Family Concerns:
R 62.5 delayed milestones
Premature 26 weeks, IVH grade 4, VP Shunt
Parent concerned with severe mobility delays not rolling in bed, not crawling, not supporting weight when
attempting to stand child, left sided neglect
ADDITIONAL DEVELOPMENTAL HISTORY
RANGE OF MOTION
Trunk: decreased rotation
Upper Extremities: WFL RUE P/AROM, demos L UE in shoulder add/IR, elbow flexion, indwelling thumb L UE
Lower Extremities: WFL PROM
STRENGTH
Cervical: 3/5
Upper Extremities: LUE 3-/5 grossly RUE 3+/5 grossly, unable to straighten elbow in quadruped, unable to maintain position indep
Lower Extremities: LUE 3-/5 grossly RUE 3+/5 grossly, unable to WB on BLE when attempted to stand
DEVELOPMENT ASSESSMENT
Rolls:
mod A, prefers rolling supine- Left side lying
Prone: when placed in prone attains prone on elbow, min A to position LUE correctly, reaches in prone on elbows with R LE,
Unable to prone on extended arm, unable to combat crawl or creep
Sit: placed in sitting maintains balance 30 secs+ CGA
Stand: total A, unable to weight bear with LE
Transitions: Supine-prone, Prone-supine, Prone-quadruped, Supine-sit: via trunk rot and unilateral UE assist
Sit-quadruped: _ mod A-maxA_____
Squat-stand: _Max A_____
Floor-stand: Max A____
Transfers: Toilet: _____ Tub: _____ Car: _______(Dependent)
POSTURAL ASSESSMNET
R trap higher>L, PPT in sitting
Tone: hypertonic L sided, UE>LE, Gait: unable to at this time Balance/Equilibrium/Protective reactions: DELAYED (sitting)
ASSESSMENT
Test Administered: PDMS-2 Peabody Developmental Motor Scales COORECTED AGE due to 14 week prematurity adjustment 11.5
months
Subtests:
Raw/Standard Score:
Age Equivalency:
Percentile %
Stationary
26/5
6 mo
5
Locomotion
RECOMMENDATIONS:
15/2
3 mo

Get your paper done on time by an expert in your field.

Order Now