[Verified Answer]: Module 14: Pediatrics, Neonatology, and…

Module 14: Pediatrics, Neonatology, and Adolescent Medicine – Report 1: Physical Therapy Initial Evaluation LOCATION: Inpatient, Hospital PATIENT: Rodney Torch PHYCISIAN: Mary Barneswell, M.D. BACKGROUND INFORMATION: Rodney is a 19-month-old boy with a history of microcephaly and possible congenital hypotonia. His prior level of function was at approximately a 10-month-old global level. He was involved in Birth to 3 therapy services and was able to roll independently and sit for short periods of time. He was able to say mama and dada. According to his mother, therapy was working on feeding, hand skills, and walking. Four days ago, Rodney had emesis, coughing and developed seizures. He was taken to an outside hospital and was transferred to The Children’s Hospital, where he developed respiratory failure with prolonged seizures. He was intubated at that time. He currently has been transferred out of ICU to the seventh floor and is on a 0.5 L of oxygen. He did have oxygen saturations that dropped to 84% during this evaluation. Physical therapy orders were received. Initial evaluation was performed on Wednesday x 2 units with the patient’s family present. Mother reports that she thinks Rodney does have some pain and that he is generally not feeling well. OBJECTIVE DATA: Range of motion: Rodney has range of motion that is within normal limits throughout his trunk and extremities. Strength/tone: Rodney has mildly decreased strength throughout his trunk and extremities. He is demonstrating antigravity movements at his bilateral lower extremities with kicking off the surface of the bed. He was resistant to weight bearing at this time and pushed back and preferred to be in supine. Gross motor skills: Rodney, at this time, was not observed to roll in bed. He was very irritable and upset. He had a pacifier in place and oxygen via nasal cannula. He preferred to be supine in bed. He required maximal assist, up to a sitting position. He was able to prop briefly in sitting using both upper extremities for a total of 1 minute. When placed in supportive stand he did not bear weight on his lower extremities. He was crying throughout and tended to arch backwards at his neck and trunk. A full assessment of his gross motor skills could not be performed due to his level of irritability. ASSESSMENT: Rodney is a 19-month-old boy who is currently admitted to The Children’s Hospital for seizure activity. He presents with range of motion that is within normal limits. He has mildly decreased tone as well as decreased strength at his trunk and extremities, which limits his gross motor skills. He is also currently limited by his illnesses and level of irritability. He does not currently want to be mobile or demonstrate any gross motor skills. Rodney will benefit from physical therapy during his inpatient stay for continuation of outpatient goals as well as to increase his activity tolerance during his inpatient stay. PLAN: Rodney will be followed by physical therapy 2 to 3 times per week. Goals for therapy include: 1. Rodney will tolerate sitting with stand by assistance using his upper extremities for play x 10 minutes. 2. Rodney will roll independently in bed both to supine and to prone to achieve comfortable positions. 3. Rodney will tolerate standing at a surface with minimal assistance to improve lower extremity strength and weight bearing. A total of 45 minutes were spent with patient.