Cva_ie This Is It

• • • • • • • • • • • • • • • • •

GENERAL INFORMATION Pt NAME: Jun Flores AGE: 45 YEARS OLD GENDER: MALE ADDRESS: 187 BASECO, TONDO, MANILA CIVIL STATUS: MARRIED CONTACT NUMBER: 412-2869 HANDNEDNESS: LEFT HANDEDNESS OCCUPATION: CASHIER TELLER RELIGION: CATHOLIC REFERRING DOCTOR: DR. TAN REFERRING HOSPITAL: PHIL. GENERAL HOSPITAL REHAB DOCTOR: DR. GO REHAB UNIT: PLM-CBR DATE OF INITIAL EVAL: FEB. 14, 2009 DX: ® MCA THROMBUS I/R: MAY FLORES(WIFE)/FAIR

HPI: PRESENT CONDITION STARTED 2 MONTHS PRIOR TO INITIAL EVALUATION, WHEN PT FELL OUT OF BED. HIS WIFE NOTED (L) SIDED WEAKNESS, SLURRED SPEECH, AND ABNORMAL POSTURE WITH HIS HEAD TURNED TO THE RIGHT. HIS MEDICAL ILLNESS IN THE PAST WAS A LEFT SUPERFICIAL FEMORAL VEIN DVT THAT HE SUSTAINED FOUR YEARS PREVIOUSLY DUE TO HIS JOB AS A CASHIER TELLER. BLOOD PRESSURE IS ELEVATED TO 140/100. PX IS TAKING ASPILET AND CHOLESTAD FOR MEDICATION. 2 WEEKS PRIOR TO INITIAL EVALUATION, PT CONSULTED REHAB MD AND WAS REFERRED TO PT FOR FURTHER REHABILITATION.

ANCILLARY PROCEDURE FINDINGS PROCEDURES XRAY

AP RADIOGRAPH SHOWED NO BONE FX

MRI

(+) OCCLUSION OF ® MCA UNREMARKABLE DX

CT SCAN

DRUG Hx DRUG INDICATIO DOSAGE Aspilet

N

FREQUEN CY

Anti160 mg coagulant

OD (for 30 days)

Cholestad Hyperlipidemia

10-20 mg

OD (evening)

PMHx (+) HTN (+) DM (--) Hospitalization (+) DVT (--) Surgical operation 

FMHx Mother

Father

HTN

--

+

DM

+

--

Heart + disease

--

PSEHx • • • • • • • •

Occasional alcoholic beverage drinker (2-3 bottles/occasion) Smoker, 14 sticks/day Educational attainment: High school graduate Cashier for 5 yrs prior to injury Pt works 8 hrs/day, 5 days/wk Poor financial support, he is presently supported by his older sister but is still insufficient Lives in a bungalow with his wife and son Pt commutes by riding a jeep and tricycle when going to work

S: C/C: Spasticity of (L) UE c difficulty in ADL  PT’s goal: To be able to restore to his maximal potential 

O: VS: BP PR RR

140/100 80 bpm 18 cpm

OI: Endomorph  Modified independent ambulation using  (+) gait deviation (see gait analysis)  (+) postural deviation (see postural analysis)  (--) attachments  (--) trophic skin changes on (B) UE and LE  (--) wound and scar on (B) UE and LE 

Palpation Normothermic

on all exposed body parts (+) synergy on (L) UE

ROM: All jts of ® UE & LE are WNL All jts of (L) UE & LE are MOTION limited ACTIVE ROM PASSIVE ROM GH flexion

0-100

0-120

GH extension

0-20

0-30

GH internal rotation

0-50

0-60

GH external rotation

0-40

0-50

GH abd

0-70

0-80

GH add

0-50

0-90

Elbow flexion

0-70

0-80

Elbow extension 0-5

0-50

Forearm

0-40

0-30

MOTION

ACTIVE ROM

PASSIVE ROM

Wrist flexion

0-40

0-60

Wrist extension

0-50

0-30

Ulnar deviation

0-20

0-30

Radial deviation

0-10

0-20

MCP flexion

0-40

0-50

MCP extension

0-5

0-15

MCP abd

0-5

0-10

MCP add

0

0

PIP flexion

0-70

0-80

PIP extension

0

0

DIP flexion

0-70

0-90

DIP extension

0-10

0-20

Thumb flexion

0-40

0-50

Thumb extension

0-30

0-40

Thumb abd

0-20

0-30

Thumb add

0-20

0-35

All jts of (L) LE are weak except Hip adduction & ankle Motion AROM PROM Plantar Flexion Hip Flexion

0-100

0-120

Hip Extension

0-10

0-20

Hip Abduction

0-30

0-40

Hip Adduction

0-30

0-30

Hip Lateral Rotation

0-30

0-40

Hip Medial Rotation

0-20

0-30

Knee Flexion

0-100

0-120

Knee Extension

0-10

0-10

Knee Medial Rotation

0-15

0-25

Knee Lateral Rotation

0-20

0-30

Ankle Plantarflexion

0-35

0-35

Ankle Dorsiflexion

0-10

0-40

Ankle Supination

0-30

0-40

Motion

AROM

PROM

Ankle Pronation

0-10

0-20

Toe Flexion MT

0-30

0-35

PIP Flexion

0-25

0-35

DIP Flexion

0-45

0-55

Great Toe MTP Flexion

0-30

0-40

IP Flexion

0-30

0-40

Toe Extension MTP 0-30

0-40

PIP Extension

0

0

DIP Extension

0-20

0-30

Great Toe MTP Extension

0-60

0-80

IP Extension

0

0

Neuroevaluation SENSORY TEST Superficial Sensation STD’s: Pinprick for pain Brush for Light Touch Blunt edge of neurohammer for Pressure Findings: Severe Loss of sensation on (L) UE & (L) face Significance: Sensory loss 2˚ to affectation of Brodmann’s (Area 312) Functional Significance: Modality Precaution

Deep Sensation Proprioception: All jts. are intact except on (L) UE Findings: Unable to identify position of (L) UE Functional Significance: Self care and workrelated considerations Kinesthesia: All jts. are intact except on (L) UE Findings: Unable to identify the direction of movement of (L) UE Functional Significance: self-care and workrelated considerations

Combined Stereognosis Perception Findings: Pt. cannot identify variety of small easily obtainable and culturally familiar objects like keys coins and balls on (L) UE. Double Simultaneous Stimulation Findings: Pt cannot perceive touch stimulus and number of stimuli on (L) UE

Tone Assessment ®UE - Normotonic (L) LE-Normotonic (L) UE-Hypertonic

® LE- Normotonic Findings: Hypertonic on (L) UE Functional Significance: self-care and work-related considerations

Memory Short Term Memory Assessment: Sequence should be repeated by the patient. Findings: pt unable to repeat the number after 5 min. Significance : Pt is unable to repeat the numbers due to ideational apraxia Visual Acuity Assessment: Peripheral eye field vision test Findings: (+) on (L) homonymous hemianopsia Significance: (L) homonymous hemianopsia d/t affectation of optic radiation in the internal capsule

DTR: BICEPS TENDON -- HYPERREFLEXIVE  TRICEPS TENDON -- HYPERREFLEXIVE  HAMSTRING TENDON-- NORMOREFLEXIVE  ACHILLES TENDON -- NORMOREFLEXIVE  PATELLAR TENDON --NORMOREFLEXIVE 

POSTURAL ANALYSIS ALL BONY LANDMARKS OF (B) LE/UE ARE LEVELED EXCEPT FOR: ANTERIOR VIEW: • HIGHER (L) SHOULDER • HIGHER (L) CLAVICLE • HEAD TURNED TO THE (R) LATERAL VIEW: • SLIGHT INCREASED THORACIC KYPHOSIS • DECREASED LUMBAR LORDOSIS POSTERIOR VIEW: • HIGHER (L) SHOULDER • HIGHER (L) SCAPULAR SPINE • HIGHER(L) INFERIOR ANGLE OF SCAPULA FINDINGS: (+) POSTURAL DEVIATIONS SIGNIFICANCE: THE HIGHER (L) SHOULDER AND CLAVICLE IS PROBABLY d/t SPASTICTY OF MM.

GAIT ANALYSIS:  CIRCUMDUCTION OF (L) LEG DURING SWING PHASE  THE (L) UPPER LIMB IS CARRIED ACROSS THE TRUNK FOR BALANCE ANTHROPOMETRIC MEASUREMENT  FINDINGS: MARKED ATROPHY OF (L) UE MM. PT IS UNABLE TO MEASURE THE (L) UE D/T MM CONTRACTURE.

FUNCTIONAL ASSESSMENT: SELF CARE EATING

4

GROOMING

4

BATHING

3

DRESSING UPPER

3

DRESSING LOWER

3

TOILETING

3

TRANSFER BED WHEELCHAIR

4

TOILET

4

LOCOMOTION WALKING OR WHEELCHAIR

6

STAIRS

5

COMMUNICATION COMPREHENSION

1

SOCIAL COGNITION MEMORY

1

LEGEND OF FIM 7

Complete Independence

6

Modified Independence (device)

Helper- Modified Independence 5

Supervision

4

Minimal Assistance

3

Moderate Assistance

Helper- Complete Dependence 2

Maximal Assistance

1

Total Assistance or not testable

PT IMPRESSION: THERE IS A THROMBUS FORMATION IN ® MCA AFFECTING THE PARIETO-OCCIPITAL CORTEX OF THE DOMINANT HEMISPHERE WHICH TYPICALLY PRODUCES APHASIA, (L) UE SPASTIC HEMIPARESIS AND SENSORY LOSS OF THE (L) SIDE OF THE BODY WITH THE (L) FACE AND (L) UE IS MORE INVOLVED THAN THE LE. • REHAB POTENTIAL: THE POTENTIAL OF THE PATIENT WILL BE GOOD IF PT WILL FOLLOW THE HOME INSTRUCTIONS GIVEN SUCH AS STRENGTHENING THE ® UE TO COMPENSATE FOR THE MOTOR AND SENSORY LOSS OF THE (L) UE. PT SHOULD ALSO BE CONDITIONED NOT TO NEGLECT THE (L) UE. THE GOAL OF THE PT MANAGEMENT IS TO •

PROBLEM LIST 1)(L) HEMIPARESIS C GREATER EXTENT TO UE 2)GR 3 SPASTICITY OF THE 9L) UE 3)ABNORMAL POSTURE 4)MOOD DISTURBANCES 5)POOR EXECUTIVE-FUNCTIONING SKILLS AND JUDGEMENT 6)SLURRED SPEECH

LTG 1)TO RESTORE (N) ADL IN 20 TX SESSIONS 2)TO WORK TOWARD ATTAINING ACTIVE MOVEMENTS 3)TO PREVENT COMPLICATION SUCH AS CONTRACTURES 4)TO BE VERSATILE 5)TO ESTABLISH PT INDEPENDENCE 6)TO ADDRESS PTS DEPRESSION (REFER TO PSYCHOLOGIST)

STG 1) TO IMPROVE ADL IN 10 TX SESSIONS 2) TO LESSEN SPASTICITY ON (L) UE IN 10 TX SESSIONS 3) TO STRENGTHEN ® UE, LE 4) TO ASSESS SPEECH PROBLEM (REFER TO SP) 5) TO ENCOURAGE SLOW AND CONTROLLED MOVEMENTS 6) TO STRENGTHEN (L) HIP FLEXORS AND (L) KNEE FLEXORS 7) TO HELP PT MOVE IN FUNCYTIONAL ATIVITIES C (N) PATTERN OF MOVEMENTS 8) TO PROVIDE REPETITION SO THAT (N) PATTERNS OF BEHAVIORS ARE LEARNED 9) TO EDUCATE THE FAMILY MEMBERS AS WELL AS THE PT HIMSELF

P: 1)CONTRACTURE ON (L) UE -- US ON THE 9L) UE USING CONTIONUIOS MODE X I HZ X 1 W/CM2 X 20 MINS, PROME OF ELBOW TOWARD EXTENSION X 10 REPS X 3 SETS 2)MM WEAKNESS AT (L) LE – PRE ON (L) HIP JT TOWARD FLEXION AND EXTENSION USING BLUE THERABAND X 10 REPS X 3 SETS BID 3)MM SPASTICITY OF (L) UE – HMP ON (L) UE X 20 MINS

HOME INSTRUCTION 1) 2) 3) 4) 5) 6) 7)

EDUCATE FAMILY MEMBERS IN UNDERSTANDING OF HOW TO ASSIST PT TO BE FUNCTIONAL AVOID PT TO BE FEEL HELPLESS OR DISABLED WHEELCHAIR MANAGEMENT ON CURBS AND OTHER UNEVEN SURFACES FOR TRAINING HOME EXERCISE PROGRAM: PROME ON (L) UE TOWARD AP ON ALL PLANES X 7 REPS X 3 SETS USE OF SQUEEZE BALL ON (L) HAND X 5 REPS X 3 SETS X 20 SEC REST INTERVAL STRENGTHENING OF ® UE USING 500ML WATER FILLED BOTTLE X 10 REPS X 3 SETS BID