Patient Name: 3 5 DOB: 10118195 Sex: Male Date: 0 1/22/08 Age: 11 Diagnosis: Spastic Quadriplegia Referring Physician: Robert Harris -. Phone Number: 573-876- 1 Student Therapists: Laura Bonham, Daniel Hodgson, Hayley Utz, Lindsey Hejlek Faculty Therapist: Jan McElroy Reason for referral . JS is an 1 1 year old boy diagnosed with spastic quadriplegia. He was referred for an evalktion at the University of Missouri-Columbia Physical Therapy Department, student lab program, due to concerns regarding recent increases in muscle tone and decreased range of motion that are negatively impacting & comfort in and tolerance for sitting and standing positioning equipment. Background information was gathered through subjective reports from mom. Social History j5 resides in Columbia, Missouri with his parents, Gary and Hester and three siblings, Isaac (7), Wyatt (5), and Gracie (4). HI'S mother is a homemaker and his father is employed in Calloway County at the nuclear power plant. J5 attends Lange Middle School where he is in a multicategory classroom with a para and a teacher. He receives Occupational, Physical, and Speech consults, but no direct therapy at school. He currently receives private Physical Therapy and Occupational Therapy one time each per week. j 5 also has nursing care on weekday mornings and respite care in the evenings two times per week. Medical History Birth History &j was a twin and at 14 weeks gestation there was a cord accident. &twin shared an amniotic sac and when the twin passed away it cut off blood flow to 15'5 Mom was told that it destroyed 50% of his brain. Jg progressed to full term and was delivered vaginally with the assistance of a vacuum extractor. 153 APGAR scores were 8 and 9. J%pzirentS took him home for one day before they returned to the hospital due to severe jaundice. He was admitted for 4 days and treated with UV light. Once b. was discharged home, his parents continued treatment in a special blanket for a specified time each day. Developmental History fj was diagnosed with cerebral palsy at 4 months old due to his muscle tone and failure o meet developmental milestones. He was also diagnosed with hydrocephalus and had a VP Shunt placed at 7 months old. He still has original shunt.In 1998 ht had bilateral hamstring and adductor tendon releases. In 1999 J 5 received his first baclofen pump. In 2000, A5 had bilateral femoral osteotomies. An X-ray of JS1s hips were taken 12/06, which indicated his hips are well seated in the acetabulea. ~5% baclofen pump had to be replaced in 2003 due to expired battery life. 35 muscle tone began to increase after the baclofen pump replacement, indicating a possible malfunction with the pump or possible resistance to the medication. ~o underwent a bolus test with positive results (decrease in muscle tone) before his third baclofen pump revision in 2006. IS. continues to show increased muscle tone despite the third baclofen pump revision. Planned Surgery J$ is scheduled for a left hamstring and adductor tendon release and a right Achilles tendon release in June 2007. His mom recently received two braces (one for his left thigh, and one for his right ankle) that hL will wear afker surgery. Current Conditions J5 has seizures that are controlled with medication, and he hasn't experienced a seizure in over a year. He also suffers from sleep apnea that is monitored every night. The alarm sounds if his HR<50 or his pulse ox <90. 35 also has hypothyroidism, controlled by medication and an underactive pituitary that is controlled by subcutaneous growth hormone injections. Medications 8:OOam 60 mg Phenobarbital 37.5 mg Zantac .05 mg Levoxyl 2 mg Glycopyrrolate (robinol) 12:OO pm 2 mg Glycopyrrolate (robinol) 6:00 pm 100 mg Zonegran 2 mg Glycopyrrolate (robinol) 8:OO pm 90 mg Phenobarbital 37.5 mg Zantac 22 units Nutropin aq (growth hormone, sub-q injection) is also on a daily continuous dose of intrathecal baclofen, delivered by his pump of about 470 micrograms a day.Home Routine J5 has a nurse come every morning and wake him up at 7:30am. The nurse gives him a bed bath, breakfast, and his morning medication. At 9:30am the bus picks h~ up and he goes to school until 2pm. tfL comes home and typically takes a nap until therapy or until his respite care arrives. He eats dinner, takes his evening medication and goes to bed at 8pm. Equipment 15 spends most of his invacare safani tilt stroller with a vest-type trunk support, hip belt, soft lateral head supports, and foot straps. He has a standing frame at home, however, he has been unable to use it for the past 9 months secondary to his decreased range of motion in his ankles. He also has night splints that keep his ankles at 90 degrees, however, he has been unable to wear those for the same reason. His parents constructed a bench for J S to lay on that will support him in sidelying. General Level of Function At 1 1 years of age, J S, is completely dependent, but demonstrates ability to follow simple commands after a processing delay. & is nonverbal, however, he communicates with sounds and some facial expression. When distressed, hc responds with low tone giggling or teeth grinding. J5 has no means of independent mobility, however, mom states that hc is able to roll from sidelying to supine. Hc enjoys attention and he is content in supine and sidelying, however, sitting and standing are becoming less comfortable due to his high muscle tone. Morphology Jj is 123 cm from head to toe and weighs 47 lbs. Leg length: right lower extremity 59 cm, left lower extremity 53 cm. Chest Expansion at xiphoid process: Inhalation: 7 1.5 cm Exhalation: 70.4 (difference 1.1 cm> In prone, h~ demonstrated decreased chest expansion on the left secondary to scoliotic curve, which yielded decreased intercostal space in the lower rib cage on the left side (left: lcm, right: 2cm). Lower limb circumference Malleoli I lOcm above I Knee joint line I lOcm above I 35 has a yellowish brown pressure area anterior to left greater trochanter. It is 3.4 cm from anterior to posterior, and 2.4 cm fiom superior to inferior at its widest points. He has 3 scabs on his left middle, ring, and pinky knuckles from rubbing the wheelchair. Right Left 4 cm 4 ?hcm medial malleoli 5 cm 4 cm 22 '/z cm 21 cm knee joint 20 cm 19 %cmFunctional Tasks Gross Motor j5 shows difficulty initiating active movement. The variability of his movement combinations is limited and thus difficult to grade. He demonstrates a