CP Chart
CP Chart
CP Chart
IP □ OP WARD
Chung Shing Hospital
No.: 011-2
Physical Therapy Neurological
Y.O.B: 1977/5/22
Initial Evaluation Form
Social and Vocational:
Brief History:
On 2022/9/27, he had R’t limb weakness while massaging. He was taken Yuanlin Christian
Hospital ER and his GCS was E4M6Va then. Brain CT showed L’t putaminal hemorrhage with
mild focal hematomas mass effect and perifocal brain edema. With the impression of
hemorrhagic stroke, he was referred to Changhua Christian Hospital and he was admitted to
SICU, conservation management was performed and his general condition became stable. On
9/29, he was transferred to ordinary ward. He ever tried hyperbaric oxygen therapy for once on
10/6. On 10/6, he was transferred to PM&R ward. He had better BP control under Exforge
5/50mg. On 10/25, he was transferred to Rehabilitation Clinic of Chung Shan Medical
University Hospital Daqing Campus. He complained about R’t shoulder pained with limited
ROM. Physical examination showed no swelling, tenderness, heat sensation, allodynia nor
muscle spasticity. Over-exercising during PT program was suspected and the symptoms
relieved after taking Cataflam for three days. Bedsides stretching and prevent over exercise
were educated for persisted R’t hand clumsiness and tightness. During hospitalized, he had
stable BP control.
After training, he could sit up independently with bedrails and had good sitting balance.
Minimal assistance was required for standing up with fair standing balance. He also started to
have ambulation training with a quadricane and under moderate assistance for short distance.
Because of persisted R’t limb weakness, he was admitted to our ward to further rehabilitation on
2022/11/28.
Precautions:
Nil
Review of Systems:
WNL ABN WNL ABN
✔️ Cardiac: ✔️ Musculoskeletal
✔️ Respiratory: ✔️ Other:
Medications:
Dosage Effect Side effect
Syntrend 25mg antihypertension Headache, vision changes, dry
eyes (decreased tearing),
diarrhea, nausea or vomiting,
joint or
muscle pain, tiredness, or weakness
Norvasc 5mg/tab antihypertension The drug was well tolerated.
Headache, edema, fatigue, nausea,
flushing and dizziness
General Observation:
He could walk into therapy room with quadricane but he need supervision by caregiver.
Mental Status/Communication:
1. Consciousness clear : JOMAC intact, M impaired (recent)
2. Communication : intact
Cooperation/Motivation:
Cooperation(Patient/caregiver) : Good/Good
Motivation(Patient/caregiver) : Good/Good
Facial/Vision:
Facial and vision : Nil
Skin and Soft Tissue:
Nil
Sensation: 踩地板的感覺 S/E/W H / K /A
Light touch NT */ intact / absent absent / absent / absent
Pinprick NT*/ absent / absent absent / absent / absent
Temperature intact intact
Joint position sense intact / intact /absent absent / impaired / intact
Joint motion sense intact / impaired / intact intact / intact / intact
Two point discrimination: NT*/ absent / absent absent / absent / absent
*: Because the sleeves are tight, it failed to direct contact his skin for those sensation tests.
Pain:
NA
Coordination:
Items (times/quality) Right Left
Finger-nose-finger 0 7 (smoothly)
Reflexes: 只有鄭根富沒有 3+
Right Left
Reflexes Response Reflexes Response
Biceps +++ Biceps ++
Triceps +++ Triceps ++
Brachioradiali +++ Brachioradiali ++
s s
Patellar +++ Patellar ++
Achilles +++ Achilles ++
Babinski sign +++ Babinski sign -
Balance Reactions/Righting reactions: Sitting Head Trunk
Balance Static Dynamic Push to R Intact Intact
Sitting S/D Normal Normal Push to L Intact Intact
Standing Normal Good
S/D
Skeletal and Joint condition (ROM, Deformities, Subluxation, Leg length discrepancies):
ROM : ROM limitation on R’t shoulder IR, hip flexion, hip IR and ankle dorsiflexion (both of
knee flexion and extension)
R’t ROM End feel
Shoulder IR 0°-45° Firm
Hip flexion 0°-100° Firm
Hip IR 0°-35° Firm
Ankle dorsiflexion (KF) -15°-0° Firm
Ankle dorsiflexion (KE) -15°-5° Firm
Deformities : Nil
Subluxation : Nil
Posture:
Transfers:
Sit to Stand I
Stand to Sit I
Bed to Chair I
Chair to Bed I
W/C to Car I
Car to W/C I
Ambulation:
Level Min. A Use quadricane
(only 4 step without quadricane )
Carpet NA
Ramps: Angle NA
Curbs: Height NA
Stairs: stairs, flights Min. A up the stairs: step over step
(hold the down the stairs: step by step (R’t LE first)
armrest) 36 Stairs
4 Flights
2 Floors
Wheelchair Mobility: NA
□Man □Elec
Level Propulsion NA
Rough Terrain NA
Ramps: Angle NA
Curbs: Height NA
Remark: Due to the poor control and coordination, he would use wrong walking pattern and even
fall down in fast speed. Therefore, regarding the safety I didn’t let him continue to increase
speed.
Equipment/Arch Barriers:
Quadricane
Assessment:
Impression: CVA /c R’t hemiplegia
Problem list:
1 Abnormal gait pattern
1) Standing phase
R’t Knee hyperextension due to
impaired joint position sense of knee
Entire sole down due to
impaired joint position sense of knee
insufficient strength of ankle dorsiflexor
ROM limitation of ankle dorsiflexion
2) Swing phase
Hip Circumduction, pelvic hiking and pelvic retraction to R’t side due to
insufficient strength of knee flexor and ankle dorsiflexor
ROM limitation of ankle dorsiflexion
impaired joint position sense of hip and knee
Moderate knee stiffness due to
insufficient strength of knee flexor
impaired joint position sense of hip and knee
hypertonia of knee extensor
Lack of terminal selective knee extension due to impaired joint position sense of
knee
Foot inversion due to extensor synergy pattern
2 Min A. on up and down stairs
hold the armrest
down the stairs in step by step (R’t LE first)
3 Poor dynamic standing balance: good
4 ROM limitation on R’t limb (affected side)
1) Shoulder IR: 0°-45°
2) Hip flexion: 0°-100°
3) Hip IR: 0°-35°
4) ankle dorsiflexion (both of knee flexion and extension): -15°-0° (KF) / -15°-5° (KE)
5 Insufficient muscle strength of R’t limb (affected side)
1) UE (proximal)
Shoulder flexion: 3- (MMT)
Shoulder abduction: 2+ (MMT)
Shoulder IR and ER: 2 (MMT)
Elbow flexion and extension: 4 (MMT)
2) LE
Hip flexion: 4 (MMT)
Hip extension: 3 (MMT)
Hip abduction: 2- (MMT)
Hip IR and ER: 3 (MMT)
Knee flexion: 3- (MMT)
Ankle dorsiflexion, plantar flexion, inversion and eversion: 1 (MMT)
6 Abnormal muscle tone of R’t limb (affected side)
1) Elbow flexor: 2
2) Wrist flexor: 1
3) Wrist extensor: 2
4) Knee extensor: 1
Ankle dorsiflexor: 2
7 Poor sensation on R’t limb (affected side)
1) Light touch on wrist, hip, knee and ankle
2) Pinprick on elbow, wrist, hip, knee and ankle
3) Joint position sense on wrist, hip and knee
4) Joint motion sense on elbow
5) Two point discrimination on elbow, wrist, hip, knee and ankle
Goals: Plan:
STG (2 weeks)
1. Correct gait pattern 1.1 R‘t foot step on football. Maintain
1) Standing phase dorsiflexion and swing the leg to roll the
Let R’t Knee maintain in neutral ball forward by the sole of foot.
position Dosage: 20 times/set, 2~3 sets
Produce R’t heel contact Cue: hip flexion first and knee
2) Swing phase full extension then.
Decrease hip Circumduction, 1.2 Leg rest on the swiss ball in supine and bend
pelvic hiking and pelvic the leg to the chest with 5kg sand bag on bil.
retraction to R’t side ankle 去感受 hip flexion 的動作
Decrease moderate knee stiffness Dosage: 20 times/set, 2~3 sets
to near normal 1.3
Produce terminal selective knee Tandem stance
extension balance
Decrease foot inversion with the
involved foot behind or in front the other
foot
Dosage: maintain 7 sec, 2 sets
1.4 Stand on one leg. Raising the opposite leg 3-5
inches off the floor
Dosage: maintain 3 sec, 2 sets
Progression: Raising the leg to
the front, back and side
1.5 L’t leg stand on the floor and the R’t leg
stand on tilting board or balance pad
Dosage: maintain 20 sec, 2 sets
Progression: Both legs on it
1.6 Lying on his back, next to a wall. Push the
foot into a swiss ball with the ball up
against the wall
Dosage: maintain 30 sec, 2 sets
Progression: increasing amounts
of pressure towards the wall
1.7 Maintain knee slight knee flexion in lunge
(R’t leg forward) 20sec, 2 sets
• Cue: knee shouldn’t over the toe.
Erect the trunk and avoid trunk
rotation.
1.8 Same as home program 1
1.9 Same as home program 2
1.10 Same as home program 3
1.11 Selective hip abduction in half kneeling
(L’t LE support)
Dosage: 20 times/set, 2 sets
Knee towards the 2rd and 3rd
toes
Contact the gluteus and lateral
knee to give cue.
1.12 Proprioception training in standing with
holding para-bar for swing phase
With mirror for visual feedback
Progression: closed eyes. If there
is a mistake, he can open the eyes
and adjust.
Hip flexion 30° and knee relax
naturally first. Then knee
extension to full range.
Dosage: 15 times/set, 2 sets
2 Decrease assistance while stepping up and 1
down the stairs 2.1 Same as home program 1
From Min A. to independent 22 Same as home program 6
23 Same as home program 7
24 Same as home program 8