INITIAL EVALUATION

GENERAL INFORMATION

Pt’s name (initials): H.I.Y

Age: 35 y/o
Sig: Onset of MS is around 20-50 y/o (O’Sullivan)
Sex/Gender: F
Sig: MS commonly affects women 2–3 times (O’Sullivan)
Address: Brgy. San Masyas, Malambot Street, City of San Fernando, Pampanga
Sig: Proximity to PT facility
Civil Status: Married
Sig: Prognosis for recovery (support system)
Handedness: R
Sig: Indicates functional limitation as to bimanual tasks
Occupation: Cashier
Sig: Condition can be occupation-related
Referring Unit: Neurology Department of Mother Teresa of Calcutta Medical Center
Referring MD: Dr. D.R
Rehab MD: Dr. R.D
Date of Referral: Sept. 22, 2023
Date of IE: Sept. 23, 2023
Diagnosis: Relapsing-Remitting Multiple Sclerosis
Informant/Reliability: Patient/Good Reliability

SUBJECTIVE INFORMATION

C/C:
Verbatim: “Hirap akong maglakad. Hindi ko maitupi nang maayos ‘yung tuhod ko at naa-out of balance ako tapos
namamanhid din. Madalas ko na rin mabitawan iyong mga pinamili ng mga costumer dahil nanginginig ang kanang
kamay ko kapag ginagalaw ko s’ya. Hirap na rin akong mag-check at mag-scan ng mga items, sumasakit din ang ulo
ko dahil siguro sa mga mata ko na nanlalabo at masakit kapag tumitingin ako sa iba’t-ibang direksyon. Dumagdag pa
na hirap ako sa pagsasalita kaya nakakahiya sa mga costumers.”

PT Translation: Pt. ℅ spasticity on ® LE that results in balance impairment, numbness on LE, intentional tremor on
her ® hand, nystagmus, & dysarthria.

Pt.’s Goal:
Pt.’s wants to ↓ spasticity to improve gait and balance, ↓ numbness, manage intentional tremor, and to be able to see
and speak properly again to perform ADLs s̅ difficulty.

HPI:
● 3 mos. PTIE, Pt. started to notice problems with her eyesight and would frequently experience difficulty in
scanning the barcodes of the items that the customers had purchased, and doing the grocery store’s
inventory became challenging for her. She also started to notice shakiness of her hands when she was about
to pick up the products from her work. After weeks of experiencing it, the symptoms disappeared for a
month and returned after a month. Pt. started to experience difficulty speaking and noticed that she got
fatigued easily. Pt. pays no heed to symptoms and resumes attending to her daily duties as her complaints
eventually resolve on their own.
● 3 wks of PTIE, Pt. symptoms heightened. Pt. started to notice spasticity in her LE that contributed to
balance problems and is unable to stand for a prolonged period of time during her working hours, which
leads to cutting short her workdays. Pt. then started to realize that her symptoms come and go for weeks to
 months, and every time they come back, they worsen, or another symptom is appearing, and decided to
visit Mother Teresa of Calcutta Medical Center. Dr. D.R. asks her questions about how the pattern of her
symptoms appeared and gives her the order to undergo an MRI to detect lesions in the white matter of the
brain and spinal cord. Dr. D.R. also advised undergoing a VEP test to further measure the electrical activity
of the brain and revealed that there is a delayed conduction. Another diagnosis used is the McDonald
Criteria of the International Panel. Pt has experienced at least two clinical attacks and has damage to the
white matter, which is a definitive diagnosis of RRMS. Dr. D.R. prescribed her corticosteroid therapy
(Methylprednisone) to help shorten the duration of the episode.
● 2 days of PTIE, Pt. returns to the hospital because the medication that was given to her wasn’t able to help
her. She was then advised to undergo plasmapharesis to enhance recovery from relapse since
corticosteroids failed to work, and she was referred to physical therapy to further manage and treat her
symptoms.

PMHx:
● (+) HTN (Controlled since 2018)
● (-) Vertigo
● (-) PD
● (-) Transverse Myelitis
● (-) Acute Disseminated Encephalomyelitis

FMHx:

Paternal Maternal Indication

HTN (-) (+)

Unremarkable as MS is
seldom familial
Vertigo (-) (-)

MS (-) (-)

PD (-) (-)

Personal/Social Hx:
● Personality: Type B
● (-) Smoking
● (-) Alcohol consumption
● Lifestyle: Inactive
● Diet: Pt. has no particular diet but mostly consumes high calorie food including dairy products and
processed foods

Home/Work Situation:
● Pt. lives in a bungalow-type house with husband and son.
● Pt. does household chores such as cleaning and cooking.
● Pt. works as a cashier from 8 AM to 8 PM daily and spends most of the time standing, and uses her
dominant hand to accomplish her job.
● Bedroom to Bathroom ~ 5 steps
● Bedroom to Living room ~ 10 steps
● Bedroom to Kitchen ~ 20 steps
Sig: Accessibility to areas of the house and work situation may contribute to the ability of Pt. to perform ADLs.
Ancillary Procedure:

Date Test Procedure Result

August 13, 2023 MRI (+) lesion on cerebral hemisphere

August 15, 2023 Visual Evoked Potentials Delayed conduction

Present Medication/s:

Medication Dosage Frequency Indication

Losartan 50 mg qd Helps to control HTN

Gilenya 0.5 mg bid Helps decreasing the

number of episodes and
may prevent or delay
disability.

Interferon beta-1a 30 mcg Once a week Helps in shortening the

(Avonex and Rebif) duration of the episode

OBJECTIVE FINDINGS

A. Vital Signs

Before During After

T° 36.6° C 36.7°C 36.9°

PR 72 bpm 90 bpm 74 bpm

RR 18 bpm 20 bpm 18 bpm

BP 110/80 mmHg 130/90 mmHg 110/80 mmHg

Findings: Pt.’s VS are WNL
Sig: For ax. And tx. Safety purposes

B. Ocular Inspection
1. Level of Ambulation
● Pt. amb c̅ AD (Quad cane).
2. Level of Consciousness
● Pt. is alert and oriented of time/place/name.
3. Body built
● Pt. is ectomorph.
4. Obvious Physical Findings
● (+) Intentional tremor on bilat. UE and LE
● (+) Postural deviation (See postural analysis)
● (+) Gait deviation
● (-) Skin breakdowns
● (-) Protective splinting
● (-) Scars
 C. Palpation
1. Thermicity
● Pt. is normothermic on all palpated areas.
2. (-) Tenderness on (B) UE & LE
3. (-) Oedema (B) UE & LE
4. (-) Shoulder Subluxation on (B)
5. (-) Muscle Spasm on ® LE

D. Neurologic Evaluation
1. LOC
● Pt. was assessed using the Mini Mental State Exam. Pt. Scored 27 pts. Which is an
indicator of normal cognition.
2. Sensory Testing
a. Superficial Somatic

Procedure Findings

Light touch Pt. was asked if the cotton ball was Intact
felt and.

Pain Pt. was asked to identify between Impaired

sharp and blunt.

Temperature Pt. was asked to identify between Intact

hot or cold.
Sig: hypersensitivity to stimuli can occur (O’Sullivan)
b. Deep Somatic

Procedure Findings

Kinesthesia Movement sense; ask Pt. to indicate 7/10

verbally the direction of the mov’t
while extremity is moving.

Proprioception Position sense; joint is moved 7/10

through ROM and held in static
position, and ask Pt. to describe the
position verbally or duplicate the
position of the extremity with the CL
extremity.

Vibration Use a tuning fork that vibrates at 8/10

128 Hz, ask the Pt. to respond
verbally, identifying the stimulus as
vibrating or non-vibrating.
Findings: Pt. has numbness in LE & cannot feel or know where their feet are that result in decreased position & mov’t
sense in LE
Sig: Disturbances in position & mov’t sense is common in MS (O’Sullivan, 2019)
c. Discriminative

Procedure Findings

2-point discrimination Pt. was asked to differentiate Intact

between one or two stimuli.

Graphesthesia Pt. was asked to identify what is Intact

 drawn in her palm.

Barognosis Pt. was asked to identify which palm Intact

has a heavy and light object when
placed.
Sig: For safety precautions in doing ax. and tx.

3. Reflex Testing
a. Muscle Stretch / Deep Tendon Reflex
Grading:
0 - absent
1 - diminished
2 - average
3 - exaggerated
4 - clonus, very brisk

0 areflexia
+ hyporeflexia
++ normoreflexia
+++ hyperreflexia
++++ clonus

Significance: To rule in UMNL

b. Pathologic Reflex

Procedure Result

Babinski Stroking of lat. aspect of the sole of (+) extension of big toe & fanning
the foot. of the small toes.
Sig: (+) Babinski is an indicative of damage in major nerve pathway.

4. Motor Control
a. Tone Assessment

Findings: Pt. scored a Grade of 1+ on ® Hip Flexor.

b. Balance
● Pt. was tested using Romberg’s test for static balance and was noted with
swaying during eyes closed. For dynamic, Functional Balance Scale was used and
 graded as fair. It was noted that pt. Able to accept moderate challenge but with
supervision.
c. Coordination
● Equilibrium Test
○ Pt. was tested using Romberg’s Test. It was noted that the pt. shows a
sign of swaying when eyes are closed.

● Non-equilibrium
○ Pt. was tested using alternate finger-to-nose test on UE. It was noted
that the pt. shows a sign of intention tremor, which worsens when it
gets closer to the PT’s finger.
○ Pt. was tested using drawing a circle on LE. It was noted that the pt. is
having a difficulty drawing an imaginary circle in the air due to the
weaknes of his ® LE
3. Cranial Nerve Testing
All cranial nerves were tested and WNL, except for:

Nerve Procedure Findings

CN II Pt. is tested using a penlight and is Impaired; absent reflex contraction

asked to follow the light as it moves
side to side

CN III Pt. is asked to follow the examiner’s Impaired; (+) Gaze-induced

finger to all 4 quadrants. Nystagmus

CN IX Pt. was asked to drink a cup of Impaired; (+) Dysphagia

water.

CN VIII Pt. is asked to fixate on a target Impaired; (+) Gaze-induced

while the examiner rotates the Nystagmus
head.

E. Range of Motion
All joints of (B) UE & (L) LE are WNL, pain free, active and passively done except for:

End Feel PROM Normal AROM End Feel

Value
(R) (L) (R) (L)

Hip Spasticity 0-11 0-20 0-20 0 0-20 Spasticity

extension

Hip flexion Spasticity 0-14 0-120 0- 120 0 0-120 Spasticity

Knee Spasticity 0-13 0-20 0-20 0 0-20 Spasticity

extension

Knee Spasticity 0-11 0-135 0-135 0 0-135 Spasticity

flexion

Ankle Spasticity 0-14 0-50 0-50 0 0-50 Spasticity

plantarflexi
on

Ankle Spasticity 0-16 0-20 0-20 0 0-20 Spasticity

 End Feel PROM Normal AROM End Feel
Value
(R) (L) (R) (L)

dorsiflexion
Findings: LOM on LE 2° to tightness.
Sig: LOM contributes to Pt.’s difficulty in amb, observable gait abnormalities, and postural instability.

F. Manual Muscle Testing

All major muscle of (B) UE & (L) LE are graded 5/5 except:

(R) MM Group (L)

1/5 Hip Extensors 5/5

1/5 Hip Flexors 5/5

1/5 Knee Extensors 5/5

1/5 Knee Flexors 5/5

1/5 Ankle Plantarflexion 5/5

1/5 Ankle Dorsiflexion 5/5

Sig: ↓ mm strength greatly affects Pt.’s ability to perform ADLs.

G. Functional Mobility
a. Gross Motor
● Pt. was tested on ↑↓ stairs with min. assistance from the PT. It was noted that the pt. is
having difficulty and moves his lower limb in a spastic gait pattern.
b. Fine Motor
● Pt. was tested for precision using the key or pulp to pulp assessment. It was noted that
pt. shows difficulty holding the key when trying to open the door.
● Pt. was tested for power using spherical assessment with the help of a ball. Pt. was
able to hold the ball for a minute and had no difficulty doing the task.

H. Special test

Procedure Findings

Lhermitte’s sign Pt. is placed in long sitting position. (+) as Pt. felt pins and needles
PT flexes patient head and one hip sensation down the spine up to LE.
simultaneously with leg straight.
Sig: Pt. may have difficulty doing ADLs as numbness can contribute to balance.

I. Anthropometric Measurement
a. Limb Girth Measurement
● Pt. was measured for limb girth on (B) UE & LE to check if there was swelling or edema in
the limbs. There were no recorded swelling nor edema on (B) UE & LE.
b. Leg Length Measurement

Reference Point (R) (L) Difference

Umbilicus to Medial 88cm 90cm 2cm

 Malleolus

ASIS to Medial Malleolus 85cm 87cm 2cm

Sig: Difference beyond 1.5cm - 2cm on LLM may contribute to the pt. balance difficulty and gate deviation.

c. Grip strength Measurement

Dominant hand ® Non-dominant hand (L)

Trial 1 21.5 kg 20 kg

Trial 2 20 kg 19 kg

Trial 3 18 kg 17 kg
Findings: Pt.’s grip strength is WNL.
J. Pulmonary Evaluation
● It was noted that there were no wheezes, crackles or rales present during the evaluation.

K. Postural Analysis
● Pt. is assessed in (N) standing position and landmark in symmetrical level, except for:

Landmark Anterior Lateral Posterior

Shoulder (L) Elevated, Slightly protracted

Elbow (L) slightly flexed

Hip Abducted Elevated

Ankle ER

L. Gait Analysis
● Pt. amb in level surface c̅ +1 min. assist and AD (Quad cane). Pt. walks in slow phase with
staggering and uneven steps in stance phase c̅ minimal foot drop and loss of balance in
midstance.

M. Activities of Daily Living Assessment

● Pt. was tested using the Barthel index outcome measure, which evaluate her difficulty with ADLs.
It was documented that Pt. was not capable to do ADLs such as dressing and ↑↓ stairs ind. and
needed +1 min assist and AD to help for balance.
ASSESSMENT

PT Diagnosis:
● Pattern 5E: Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the
Central Nervous System
PT Impression:
● Pt. was medically diagnosed with RRMS as manifested by optic neuritis, dysarthria, intentional tremor on
bilat. UE. and a presentation of ® LE spasticity that results in difficulty maintaining balance. Pt. has sensory
impairment as to proprioception as manifested by intentional tremor, and impaired CN II.
Prognosis & Rehab, Potentials:
● Pt.’s condition falls under a good prognosis considering her sex and age. One factor that also helped is that
the family remains positive and supportive of her therapy sessions. PT will continue to keep an eye on the
patient's s/sx as well as her diet and medication intake.

Problem List:
1. Difficulty in performing self-care activity such as dressing, and ↑↓ stairs.
2. Balance impairment.
3. Spasticity on ® LE.
4. Sensory deficit on LE.
5. Intentional tremor on (B) hands.

Preventive Goals:
● Pt. will be able to prevent 2° complications such as atrophy and immobility by following the PT Mx &
treatment plan. Pt. will also be able to recognize the aggravating factors of her dse. to mitigate the dse.
Rehabilitative Goals:
● Long Term Goals (LTG):
1. Pt. will be able to perform ADLs such as dressing and ↑↓ stairs, as manifested by the ability to tie shoelaces
and wear bottoms, and amb. ind. s̅ AD w/in 3 mos.
2. Pt. will be able to improve balance from excessive swaying to no evident sway in Romberg’s test and a Fair
to (N) grade in FBS as manifested by the ability to balance and weight shift in all direction independently
w/in 4 mos.
3. Pt. will be able to improve gait by reduced staggering and amb. in (N) speed as manifested by the ability to
amb. ind. w/in 6 mos.

● Short Term Goals (STG):

1. Pt. will be able to perform ADLs such as dressing, as manifested by the ability to wear bottoms ind. c̅ + 1
min. assist w/in 3 wks.
2. Pt. will be able to improve balance from swaying to decrease swaying in Romberg’s test and a fair to good
grade in FBS, as manifested by the ability to balance and weight shifting while turning head/trunk c̅ +1
mod. assist w/in 3 wks.
3. Pt. will be able to improve gait by reduced staggering, as manifested by the ability to amb. c̅ +1 min. assist
of AD w/in 4 wks.
4. Pt. will be able to increase intact sensation from 5/10 to 9/10, as manifested by the ability to perform safe
ambulation.
5. Pt. will be able to ↓ intentional tremor by improving performance of alternate finger-to-nose test as
manifested by the ability to reach and scan items w/in 3 wks.

Participation Goals:
● Pt. will be able to return to work c̅ the ability to sustain prolonged standing during her working hours, and
will be able to min. occurrence of tremors on activities requiring reach and grasp such as handling goods,
swiping cards and pushing buttons.

PLAN

Prescribed PT Mx:
1. Static balance exercise on stable → unstable surface and bilat. leg stance → single leg stance x 10 reps x 3
sets
2. Dynamic balance exercise: heel toe walking x 10 steps x 5 times
3. PNF exercises of repeated stretch on LE x 10 reps x 3 sets.
4. AROMe on (B) hip and knee flex and ext, (B) ankle PF and DF x 10 reps x 3 sets
 5. ES on rectus femoris & VMO mm. of (R) LE x 2 hz x 200 ms x 2 sec. On; 2 sec. off.
Suggested PT Mx:
1. Aerobic exercise such as walking x 2x/week x 30 min/day.
2. Stretching exercises such as yoga x 10 min/day.
3. Strengthening exercises x 3x/wk.
4. Ice massage x 15 min. X 3x/day.
5. Suggest the pt.’s family about consulting a speech pathologist to assist Pt. in treating speaking problems.
6. Suggest the pt.’s family about consulting an opthalmologist to assist Pt. in treating visual problems.

Home/Ward Instructions:
1. Educate the pt.’s family about the condition and encourage pt. To actively participate in doing home
exercise.
2. Exercise should be done in moderate intensity, as fatigue is contraindicated to the pt.’s condition.
3. Maintain a healthy and smoke-free environment.
4. Educate the pt.’s family to check the room temperature first, as 35°C- 40°C temperature could trigger the
symptoms.

Frances Sophia C. Cunanan, SPT

Justin Mavric M. Pangilinan, SPT