Submitted by:

Neha Noor
Sap id: 3307
DPT (8th Semester)
Submitted to:
Mam Nazish Rafique

Topic:
“Write SOAP note of given case”

Assignment no 3

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Case:
A 67 year old hypertensive, diabetic, hypercholesterolemic, obese, sedentary man
with prior history of coronary artery disease, peripheral vascular disease, and
transient ischemic attack develops left facial numbness, vertigo and gait
disequilibrium. This develops four days after an episode of emotional stress during
which he is accused of causing a labor dispute involving his labor union.
The past history is significant for transient ischemic attack, intermittent
claudication and unstable angina.
The physical exam reveals BP 200/110, pulse 80. The neurologic exam reveals a
broad based gait and a left Horner's syndrome. There is left facial and right body
anesthesia, left dysmetria, decreased gag and palatal reflex, and dysarthria.

SOAP note:
Subjective:
Demographics:
Age: 67 years Occupation: Laborer
Diagnosis: Stroke
Chief complaint: Patient develops left facial numbness, vertigo
and gait disequilibrium and also having chief complain of transient
ischemic attack, intermittent claudication and unstable angina due
to episodes of emotional stresses in his occupational life.
History of presenting complain: Patient is of old age and having
high blood pressure levels, high cholesterol levels and he is also
diabetic. He is obese and living in sedentary lifestyle. After having
dispute with his fellow workers in his union he developed
emotional stress which ultimately leads to persistent stress on his
body and causes coronary artery disease, peripheral vascular
disease and transient ischemic attack. These conditions ultimately

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 causes other symptoms such left facial numbness, vertigo and gait
disequilibrium. He was referred to physical therapy department for
further evaluation and treatment.
Past medical history: HTN+, DM+, Hypercholesteremia
Social history: He is obese and his lifestyle is sedentary. He is
also facing emotional stresses from his occupational side.

Objective:
Blood pressure: 200/110 mm of Hg
Pulse rate: 80 beats / minute
Temperature: A/F
Other: The neurologic exam reveals a broad based gait and a left
Horner's syndrome. There is left facial and right body anesthesia,
left dysmetria, decreased gag and palatal reflex, and dysarthria.

Assessment:
 On neurological assessment, we can conclude that patient is
having broad base gait, left Horner’s syndrome, left facial
and right body anesthesia, left dysmetria, decreased gag and
palatal reflex and dysarthria.
 On physical assessment, his B.P levels are raised and lack of
co-ordination can also be clearly seen in his body, he is
having left facial numbness, vertigo and gait disequilibrium
on gait assessment.
 MMT assessment shows general muscle weakness.
 Berg balance scale, reading shows lack of sensory balance
in patient.

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Plan:
Short term goals:
 To reduce weight.
 To improve bed mobility.
 To improve functional activities.
 To improve balance.
 To improve bp levels, cholesterol levels and sugar levels of
patient.
 To improve speech.
Long term goals:
 To strengthen weak muscles of body.
 To improve reflexes.
 To improve quality of life.
 To improve general range of motion.
 To improve ADL’s and IADL’s.
 To increase awareness of self-safety.
Physical therapy treatment:
 Strengthening of weak muscles.
 Endurance training.
 Single leg standing.
 Heel raises, side walking.
 Step walking.
 Heel to toe walking.
 Facial exercises.
Home plan:
 We advise patient to perform low impact exercises which does not
provide harm to him as he is lacking balance.

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 We suggest some endurance exercises for strengthening of weak
muscles.
 Also advise him to consult occupational therapist and speech
therapist to improve quality of life.
 Heel raises, side stepping with holding initially and then perform
these without holding on.
 Squats against gym ball, single leg standing.
 When he develop balance then perform backwards walking.
 Also ask him to reduce weight so he can have better functioning in
his life which also leads to improvement in his quality of life.