Context of assessment: The student has been requested to perform an assessment in a regional outpatient clinic for a patient referred with leg pain and a recent change in walking ability. The family has recently moved to the region and limited background information is available.
Setting: Regional Physiotherapy outpatient clinic
Patient age: 12 years
Main Presentation: GMFCS 3 CP spastic diplegia with recent change in walking ability
Student Name: Hannah
Educator Name: Richelle
Patient and parent name: Kiara & Alex (Mother)
Reason for referral to physiotherapy:
GP referral as parent presented to GP with concerns about her walking – changed walking pattern and complaining of pain in her legs Left and Right. New referral to the service due to family relocation.
History of presenting condition:
Onset approx. 3 weeks ago, has been getting worse. Not troubling her sleeping patterns. No pins and needles or other symptoms. Pain is in calf muscles. Not wanting to walk as much as usual, reduced participation in school PE and family time at the park on weekends.
Current mobility – uses a K-walker majority of the time but will take a few steps without (holds furniture/parents hand) FMS 4,2,2
Nil related to current problem.
Last hip x-ray 4 months ago when had her annual review at the children’s hospital, stable migration percentages (R=15% and L=23%)
Paediatric Rehabilitation multidisciplinary team at tertiary hospital – 6-9 monthly for BoNT-A injections, serial casting as required, AFO modifications etc.
Opthalmology, Orthopaedics & Gait laboratory, Orthotist
Past medical history:
Mild hydrocephalus associated w/ IVH, nil shunt required.
Nil ongoing visual issues.
Ex K29/40, BW 1315g. Spent 3 months in neonatal units. MRI showed bilateral Gr 3 IVH.
Past surgical history:
Opthalmology – squint surgically repaired @ 2yo (infantile onset esotropia)
Orthopaedics – bilat FDROs @ 8yo
Developmental history & ADLs:
W-sit indep at 18mo
Furniture walked at 24mo, K-walker at 3yo
Continent at 3yo bladder and bowels.
Independent with toileting.
Sits to shower due to fatigue and reduced balance.
Has trouble w/ donning AFOs, can remove indep.
Movicol prn for constipation
BoNT-A injections for spasticity
Social & Family History:
Attends mainstream school, has PI ascertainment. 6 monthly IEP in place for physical assistance. Some classroom learning support required. 2 siblings – 9yo brother and 14yo sister. Mum and Dad both work, Dad owns his own business and works from home so usually brings Kiara to her appointments. Family dog. Very outdoor active family, weekends are always sports/park/picnics etc. Family have recently relocated to this small town, so no past contact with the regional physiotherapy service.
Concern with her change in activity levels and onset of pain. Goals to return to usual function, pain free.