GI

Patient’s Initials: A. B
Age: 35 yrs old
Sex: Female
Address: Mandaluyong City
Civil Status: Married
Handedness: Right
Occupation: Gym Instructor
Religion: Roman Catholic
Referring Unit: Our Lady of Lourdes Hospital, OPD
Referring MD: Dr. A. C (Neurologist)
Rehab MD: Dr. M.D
Date of Consultation: August 15, 2017
Date of Referral: August 15, 2017
Date of IE: August 15, 2017
Medical Diagnosis: Relapsing Remitting Multiple Sclerosis

HPI:

Present condition started 5 months prior to PTIE when pt was on her way home pt felt a
pain at the back of her eyes and felt a blurry vision. Pt took some rest because she thinks it was
just because she is tired.
4 months prior to PTIE, patient again felt a pain at the back of her eyes and felt a blurry
vision and it was relieved after 5 mins. Pt did not fell ay other symptoms at this month.
3 mons prior to PTIE, pt was about to finish her jog at night for `2km, she felt a
numbness on her ® lower extremity, this lead the pt to stop and took some rest. Pt just then
ignore it and did not took some medication d/t tiredness of exercise.
2 months prior to PTIE, pt did not felt any other symptoms in this month.
1 month prior to PTIE, while pt was at work pt again felt the pain at the back of her eyes
and felt so tired also experiencing a double vision and easily get’s irritated.
1 day prior to PTIE, pt still experience the symptoms. But this time it become worsen,
she felt numbness and weakness on ® upper and lower extremities that leads her to loss
balance while she was walking also experiencing a double vision and slurred speech. Her
overwhelming tiredness persist throughout the day and patient also cannot tolerate the heat
anymore. Her condition worsen that she was unable to do her basic ADL’s and IADL’s. this
prompted the pt to seek for medical attention. Pt was lifted by her husband and son. They
brought her at Our Lady of Lourdes Hospital and was arrived ~ 5 mins. Upon arrival pt was
attended by Dr.A.C. upon physical examination, the ff are being noted: (+) lhermitte’s sign, (+)
mm weakness on arm and leg, (+) heat tolerance, (+) tic doulourex. Dr. A. C suspected a
possible MS so he ordered an MRI (see ancillary procedure) and revealed a plaque formation
on the posterior and lateral funiculi of cerebellum and brainstem. Pt was diagnosed with RRMS.
At present complains easily fatigue, difficulty in ADL’s and weakness on ® UE and LE.
ANCILLARY PROCEDURE
Procedure Date Performed Result Significance
MRI August 15, 2017 (+) plaque formation (+) MS
 at the cerebellum and
brainstem

MEDICATION
Route Dosage Indication
Drug
Amantadine Oral 200mg once a day To decrease the
fatigue in the early
morning
Pemoline Oral 200mg once a day To decrease the
fatigue in the
afternoon

PMHx
 (-) Hospitalization
 (-) HTN
 (-) DM
 (-) Heart Dse.
 (-) Seizure
 (-) Food and drug allergy
FMHx
FATHER MOTHER
HTN (-) (-)
DM (-) (-)
Heart Dse. (-) (-)

PSEHx
 Non-Cigarette Smoker
 Non- alcoholic beverage drinker
 Active lifestyle
- Jogs 2 times a week
 Loves to eat meat and vegetables
 Work as a Gym Instructor (~8hrs/day 5x a week)
Home-set-up
 Pt lives with her husband and 1 son in a 2-storey house
- 15 meters at the main gate
 Having the bedroom as the main reference:
o ~10 meters to bathroom
o ~25 meters to living room
o ~30 meters to kitchen
o ~35 meters to front door
o 2 flights of stairs, 10 steps, 6 inches per staircase
o Steps height: ~7 inches
o Bed height: ~2 ft
SUBJECTIVE
C/c: “mabilis akong mapagod, nanghihina ang aking kanang kamay at binti kaya nahihirapan
ako mag lakad”
PT translation: Pt tends to be fatigue always in small activities and has a hard time in walking
d/t weakness on ® arm and leg.
Pt’s Goal: To be able to regain strength on ® arm and leg and able to go to work without getting
easily fatigue.
Pt’s Attitude: Pt is cooperative and motivated

OBJECTIVES
Vital Sign
Normal Before After
BP 120/80mmHg 120/80mmHg 11/80mmHG
RR 12-20 cpm 18 cpm 18 cpm
PR 60-100 bpm 70bpm 72bpm
Temperature 37 37 37
Findings: all VS are WNL
Significance: for baseline and precaution to exercise

OI
 Ambulatory s assistive device (quad cane)
 Endomorph
 (+) gait deviation (see gait analysis)
 (+) Nystagmus
 (-) facial asymmetry
 (-) skin trophic changes
 (-) diplopia
PALPATION
 All body parts are normothermic includes ant. and post. aspect of the trunk.
 (-) edema
 (-) swelling
 (-) Tenderness
SENSORY TESTING
Superficial Sensation
LEGEND
0= absent 4= normal response
1= delayed response NT= not testable
2= exaggerated response P= proximal D= distal
3= inconsistent response
Sensation STD L R
Pain Using Pin (B) UE & LE and 4 4
face
Light touch Using Brush (B) UE & LE and 4 4
face
Pressure Using Thumb (B) UE & LE 4 4
 face
Temperature Using Hot and (B) UE & LE and 4 4
cold test tube face
Findings: pt is hypersensitive to painful stimulus especially heat
Significance: for baseline purpose and modality precautions.
DEEP SENSATIONS
Deep sensations of B UE and LE B sides has been tested and are WNL c grade of 4 except: R
side of Body
SENSATION PROCEDURE RESULTS
Vibration Tuning fork was used R-4
and was contacted on the L-1
bony prominences of B UE
and LE of B sides of the
body
Kinesthesia Thumb, wrist, elbow, R-4
and shoulder were moved to L-1
assess kinesthesia of UE.
Big toe was moved to assess
kinesthesia of LE.
Proprioception Thumb, wrist, elbow, R-4
and shoulder was moved to L-1
assess proprioception of UE.
Big toe was moved to assess
proprioception of LE.
Findings: ® side deep sensation of R UE and LE are delayed
Significance: this could cause the pt to drop held things and have an unstable gait
Reflexes
DTR
Legend:
0 = Areflexia
+ = Hyporeflexia
++ = Normoreflexia
+++ = Hypereflexia
++++ = Clonus
Pathologic Reflex

Reflex Elicitation Response

Babinski Reflex Stroking of the lat. Aspect of Extension of big toe and fanning of 4
sole of foot small toes
Chaddock’s Stroking lat side of the foot Extension of big toe and fanning of 4
beneath lat malleolus small toes
Oppenheim’s Reflex PT stroke the (R) lateral foot (+) Extension of big toe and fanning of
beneath medial malleoli four toes
Findings: pt has (+) Babinski, Chaddock’s, Oppenheim’s sign and absent superficial abdominal
reflex
Significance: manifestation of demyelinated CST
Cranial Nerve Testing
CN TEST Findings
2 Test peripheral vision by Pt was able to identify the objects
confrontation however blurring of vision reported
Direct light at the side of B eyes;
check for pupillary constriction

5 Uses cotton for light touch on (+) tic doulourex

ophthalmic, mandibular and
maxillary distribution
7 facial expression Raise eyebrows, frown, smile, (+) facial myokimia
close eyes tightly, puff out both
cheek
7taste to ant 2/3 of Apply saline solution and Pt has intact sense of taste on ant 2/3
tongue sugar using a cotton swab therefore he won’t lose appetite

8 Rinne Test (+) dysequilibrium

Findings: decreased CN 2, 5 and 7 integrity

PHYSICAL ASSESSMENT
ROM
AROM/PROM of B sides of the body including neck was assessed and is WNL except:
Motion N AROM PROM DIFF END FEEL
Cervical 0-45 0-20 0-25 20 Empty
Flexion
Findings: pt is unable to complete ROM d/t electric like pain radiating on R UE and LE
Significance: (+) Lhermitte’s sign
MMT
All muscle group on both UE and LE are grossly assessed and graded 5/5, except for:
Muscle Group ® Grade
Shoulder Flexors 3+/5
Shoulder Abductors 3+/5
Elbow Flexors 3+/5
Wrist extensors 3+/5
Hip Flexors 3+/5
Hip Abductors 3+/5
Knee Flexors 3+/5
Knee extensors 3+/5
Ankle DF’ors 3+/5
Ankle PF’ors 3+/5
Significance: Pt may have difficulty in performing ADLs and difficulty in ambulation.

GAIT ANALYSIS
Stance Phase Increase
Swing Phase Decrease
Findings: Pt. walks slowly and C wide BOS
Significance: pt has poor balance while walking

ASSESSMENT
PT Diagnosis: Impaired Motor Function and Sensory Integrity Associated with Progressive
Disorders of the Central Nervous System
PT Impression: Pt. was medically diagnosed with Relapsing Remitting Multiple Sclerosis and
FS grade 2(sensory function). MRI showed (+) plaque formation on the cerebellum and
brainstem and cranial nerve II, V, VII and VII with no attacks noted. She presented with (+) tic
doulourex, (+) hyperpathia, (+) hyperflexia on ® EU and LE, (+) Lhermitte Sign, LOM on ® UE
and LE, postural tremors, walls with wide BOS.

Rehab Potential
Pt. has fair rehab potential due to:
 Course of dse which is progressive and tended to get worse over time.
 Late onset of symptoms and starts with motor dysfunction.
 Pt will requires to have lifetime treatment as the dse progresses.

Problem List
 Easily Fatigue
 Poor Coordination
 Nystagmus
 Moderate difficulty in performing ADLs such as eating, grooming, UE and LE dressing,
toileting an ambulation.
 Weakness on all major muscle groups of UE and LE

STG
 Pt will perform regular exercises to prevent further weakness of mm and to improve
motor function for the pt to adapt the dse.
 Pt will be able to perform basic ADLS from moderate to minimal.

LTG
 Pt will perform regular exercises to maintain motor performance, strength, flexibility,
ROM, balance and ambulation.
 Pt will ambulate without any use of assistive device on even and uneven surfaces
 Pt muscle strength will inc to grade 5 from 3+ within 5 weeks.
 Pt will inc endurance for 4 weeks

PLAN:
Precautions:
1. Pt must avoid exacerbating factors and must be treated with care and within cool
environment temperature.
2. Treatment should be in early morning and late afternoon.
 3. Monitor the effects of fatigue, and attenuated HR & BP during exercise.

PT Management
1. Jacobson’s exercise
2. AROM of B UE & LE x 10 reps x 3 sets
3. GPS of (B) UE/ LE x 15 sh x 5 sets
4. Bicycle ergometer X 20 mins to increase endurance
5. Balance exercise

Home exercise program:

1. Energy conservation technique
2. Relaxation technique
a. DBE x 10 reps x 3 sets 3xaday

Olayvar, Arah A.
12-00546/ BSPT 4