PT Notes

(05/09/2022)

SUBJECTIVE:
General Information:
Patient’s name: Kwek, Gilbert
Age: 63
Sex: Male
Diagnosis: Acute stroke

Cc:
● Caregiver c/o immobility further defined by muscle weakness & inability of the pt to move
his (R) UE & LE

OBJECTIVE:
VS
VS Before After

BP (mmHg) 120/70 mmHg 125/80 mmHg

PR (bpm) 77 bpm 81 bpm

02 sat (%) 95% 92%

Findings: Pt’s VS were all WNL except for O2 sat which was below the normal values.
Significance: Pt was still able to continue & performed prescribed PT Mx but c utmost precautions &
close monitoring of VS for any possible changes & to ensure safety.

OI
Pt. is lethargic, incoherent but cooperative
Mesomorph
Bedridden
(+) Facial asymmetry (See CN Assessment)
● (L) side is higher than the (R) side
(+) Dysphagia
(+) Attachments on the face & (L) UE
● IV line on (L) Dorsal aspect of the hand
● Nasal cannula
● NGT
(+) Small wound on (R) anterior aspect of the lower leg
(-) Inflammation on (B) UE & LE
(-) Swelling on (B) UE & LE
(-) Drooling
(-) Atrophy on (B) UE & LE
(-) Contractures (B) UE & LE
(-) Pressure sores

Palpation
Normothermic on all exposed body parts
Normotonic on (L) UE & LE (See Tone Assessment)
Flaccidity on (R) UE & LE
(+) Non-pitting Edema on (R) Hand
● 1+ : Indentation is barely detectable
(+) Scaly & dry skin on (R) UE & LE
(-) Tenderness on (B) UE & LE
(-) Tightness on (B) UE & LE
(-) Muscle spasm on (B) UE & LE
(-) Muscle guarding on (B) UE & LE
(-) Pressure sores on bony prominences
(-) Dislocation on wrist, elbow, sh, hip & ankle jts
(-) Subluxation on elbow, sh, hip & ankle jts
(-) Crepitus on (B) UE & LE

FMT
Reaching Overhead in Supine

Grading
Pt’s Response
R L

Pt. was assessed in supine position; was not able to

O F
initiate & perform the activity on his (R) UE but
(No Function) (Functional)
was able to do it indep but c min diff on his (L) UE

Cone Reaching

was not able to initiate & perform the activity on his O F

(R) UE but was able to do it indep but c min diff on (No Function) (Functional)
his (L) UE

Grasping and Gripping PT’s hand

Pt. was assessed in supine position; was not able to

O F
initiate & perform the activity on his (R) LE but
(No Function) (Functional)
was able to do it indep but c min diff on his (L) LE

Heel slides

Pt. was assessed in supine position; was not able to

O F
initiate & perform the activity on his (R) LE but
(No Function) (Functional)
was able to do it indep but c min diff on his (L) LE

Ankle Pumps

Pt. was assessed in supine position; was not able to

initiate & perform the activity on his (R) LE but was O F
able to do it indep but c min diff on his (L) LE (No Function) (Functional)

Tone Assessment
All major muscles of (B) UE & LE were assessed & graded using MAS & were found N in tone
Grade
Muscle Group
R L

Shoulder flexors 0 0
 Shoulder extensors 0 0

Elbow flexors 0 0

Elbow extensors 0 0

Wrist flexors 0 0

Wrist extensors 0 0

Hip flexors 0 0

Hip extensors 0 0

Knee flexors 0 0

Knee extensors 0 0

Ankle DF 0 0

Ankle PF 0 0
Findings: Pt. exhibits N muscle tone on (B) UE & LE since pt’s stroke condition was addressed
immediately c Mx & early rehab was recommended.
Significance: This may be a factor to consider since possible impairments such as spasticity may be
prevented & will not hinder PT Mx & rehab

CN Testing
CN Procedure Results

3: Oculomotor Opening of eyelids Pt was able to only perform lateral

4: Trochlear gaze in visual tracking. Upward,
6: Abducens Eye movements (Visual Tracking): medial and downward gaze were
● Upward gaze affected.
● Downward gaze
● Medial gaze Pt was not able to move his eyelids of
● Lateral Gaze the (R)

Assessing of constriction of the Constriction of (B) pupils were

pupils c light normal/ intact

7: Facial Closes eyes tightly Pt was able to do it on the (L) side but
Raises eyebrows was not able to move & perform it on
Smile the (R) side of his face
Puff cheeks
Significance: Pt presents c an asymmetry on his face, impaired upward, downward and medial gaze,
and inability to move eyelids on the (R) is may be d/t his acute stroke condition that affected the
cranial nerves responsible on the above mentioned procedures

Coordination Assessment:
Non-Equilibrium

Activity Findings R L
 Pointing & Past Pt was graded 3 on his (L) UE since the pt. presented
Pointing with min impairment & able to accomplish the activity c
slightly less than normal control, speed & steadiness. 1 3
However, on his (R) UE the pt was graded 1 since there
was a severe impairment wherein the pt was not able to
initiate nor perform the activity

Knee Pt was graded 3 on his (L) LE since the pt. presented

extension/flexion with min impairment & able to accomplish the activity c
slightly less than normal control, speed & steadiness. 1 3
However, on his (R) LE the pt was graded 1 since there
was a severe impairment wherein the pt was not able to
initiate nor perform the activity
Significance: Pt will have max difficulty in doing BADLs such as reaching an object, STS, & amb
since coordination in this side is impaired

ASSESSMENT
Problem List:
1. Muscle weakness of (R) UE & LE
2. Poor grip strength on his (R) hand
3. Non-pitting edema of the (R) hand
4. (R) UE and LE Coordination problem
5. Facial asymmetry
6. CN problem

PLAN
MD Suggested Plan
Pt will be seen & treated with the ff PT Mx:
● AAROMEs of the (L) UE & LE x 10 reps
● PROMES of the (R) UE & LE x 10 reps
● ES of (R) UE & LE x 10 minutes
● GPS (B) HC x 30 sH x 3 reps
● MBRE c cone reaching of the (L) UE x 2 rounds (AM)
● HBRE c cone reaching of the (L) UE x 2 rounds (PM)
● Short Sitting Balance Tolerance exercise c feet dangling x 5 mins

PT Suggested/Additional Recommendation:
● Bobath approach: Bed mobility from supine → side-lying towards the unaffected side x
repositioning every 2 hours to regain motor control and not to promote compensations &
improve efficiency of movement to the patient’s maximum potential
○ Key points of control:
■ Shoulder girdle
■ Knees
○ Reflex inhibiting pattern
■ Clasping of the hands
● Bobath approach: Bed mobility from side-lying → sitting x 5 reps or as tolerated by the
patient to regain motor control and not to promote compensations & improve efficiency of
movement to the patient’s maximum potential
○ Key points of control:
■ Shoulder girdle
■ Mid back
○ Reflex inhibiting pattern
■ Extension and external rotation of the shoulder and wrist & finger extension
● Bobath approach: Sitting → Standing x 5 reps or as tolerated by the patient to regain motor
control and not to promote compensations & improve efficiency of movement to the patient’s
maximum potential
○ Key points of control:
■ Head
■ Shoulder girdle
○ Reflex inhibiting pattern
■ Lateral flexion of the neck towards the normal side
● Bobath approach: Controlled movement of the elbow x 5 reps or as tolerated by the patient to
increase ROM and joint mobility and integrity
○ Key points of control:
■ Head
■ Hands
■ Mid Thoracic regions
○ Reflex inhibiting pattern
■ Clasping of the hands
● PNF approach: D1 flexion slow reversal hold of (R) LE x 6 sec hold x 5 reps to improve the
mobility of the hemiplegic limb
● PNF approach: D1 flexion slow reversal hold of (R) UE x 6 sec hold x 5 reps to prepare
mobility of the patient for indep feeding and self-care activities such as donning, doffing of
clothes and bathing
● Coordination exercises of the (R) UE and LE x 10 reps each
○ Pointing and past pointing
○ Finger to Therapist’s finger
○ FA Pronation/Supination
○ Alternate flexion/extension of the knee
● Facial expression exercise x 10 reps
● Sitting Lateral Weight shifting balance exercise x 5 reps
● Standing tolerance exercise c close guarding, & guard belt x 5 mins