Case Presentation 2

NAME: POOJA SURVE

MPT ORTHO
RA2122204010014
Demographic Data

 Full Name : Mr. Jagannathan

 Age : 50 years
 Gender : Male
 Dominance : Right
 Ward : Neurology
 UHID No. - 2153937
 IP No. – 2129096
 Date of assessment- 21-09-2021
 Chief complaints :
 Difficulty in moving the left side of the body
 Difficulty in performing ADLs
 Difficulty in walking.
 Past history :
 Past Medical – HTN since 3 years
 Past Surgical – None
 Family history : none
 Personal history :
 Appetite – Reduced
 Sleep – Disturbed
 Narcotic addiction - None
 Alcohol addiction - None
 Bowel – Normal
 Bladder – Normal


Socioeconomic history :
 Kuppuswami Scale
Physical Examination
 General Examination :
Blood pressure : 130/85 mmHg (Assuming based on atherosclerosis)
Temperature : 99.2 F (Assuming based on complaint of fever)
Pulse rate : 72 beats/min
Respiratory rate : 19 breaths/mi
 Systemic Examination :
 On Observation
Built : Endomorphic
Nutrition : Mixed
Pallor : Absent
Icterus : Absent
Oedema : Absent
Attitude of the Patient : Supine lying
 On Observation :
 Posture and Gait : (with support)
 Shoulders protracted
 Chin protruded
 Hip in external rotation
 Hyperextension of knee
 Inversion of foot
Gait – Circumductory gait

 On Palpation :
 Clubbing : Absent
 Cyanosis : Absent
 Oedema : Absent
 Tenderness : Absent
Nervous System Examination

 Higher Mental Function

 Coordination : Cannot be assessed

due to weakness
 Communication – Affected (slurred speech)
 Cranial Nerve Assessment
 CN I - Sense of smell in each nostril
 CN II –
 Acuity of vision
 Field of vision
 Color vision
 CN III, IV, VI - External Ocular Movements
 CN V - Sensations over the face, Corneal, Conjunctival, Jaw Jerk ○
 CN VII - Expressions
 CN VIII - Rinne’s test, Weber’s test
 CN IX, X – Uvula “Ah” , Gag reflex
 CN XI - Trapezius, Sternocleidomastoid
 CN XII - Protrude tongue
 Involuntary Movements - Absent
Motor System Examination

 Range of Motion :
Active Rom reduced on the left side
Passive Rom Full

 Tone :
 Left side – 1+
Power :
 MMT –

 Left – 2/2+
 Right -4
Reflexes

 Superficial
 Plantar - +
 Abdominal - +
 Deep
 Biceps - +
 Triceps - +
 Supinator - +
 Knee - +
 Ankle - +
Sensory System Examination

 Superficial Senses
 Touch - Diminished on the Left side
 Temperature - Diminished on the Left side
 Pain - Diminished on the Left side
 Deep Senses
 Position - Diminished on the Left side
 Joint sense - Diminished on the Left side
 Vibration - Diminished on the Left side
 Cortical Senses
 Tactile Localization - Diminished on the Left side
 Tactile Discrimination - Diminished on the Left side
 Stereognosis - Diminished on the Left side
Investigations
CT scan shows ( RT ) middle cerebral artery infarct

Diagnosis
Medical Diagnosis – Right Middle Cerebral Artery Infarct
Physiotherapy Diagnosis – Inability to use the left side of
the body and weakness secondary to right MCA infarct.
Problem List

 Tonal abnormalities
 Muscular weakness
 Functional disability

 Possible Problems in Post Stroke

 Synergistic pattern
 Tightness & contracture
 Imbalance & incoordination
 Gait abnormalities
 Postural abnormalities
 Deconditioning
Goals
Long Term(Sub-Acute and Chronic Phase)
 Short Term(Acute Phase) Maintain all short term goals
 To make the patient Improve sensory function
aware about the status of Flexibility & joint integrity
his condition Improve strength
 Improve respiratory & Manage spasticity
circulatory function Improve motor control
 Prevention Improve upper extrimity function
of secondary
complications Improve balance
Improve locomotion
 Prevent from Improve aerobic function
deconditioning Discharge planning
Management :
– To Improve respiratory & circulatory
function
 Interventions
 Breathing exercise
 Chest expansion exercise
 Postural drainage
 Huffing & Coughing techniques
 Passive & active ankle & toe exercise
(after careful & thorough examination of cardiopulmonary
system)
– To Prevent pressure sores

 Interventions
 Proper positioning
 Relieve pressure points by padding & cushion
 Frequent turning & changing position
 Prevent from moisture
 Tight fitting cloth to be avoided
 Use of waterbed, air bed & foam mattress
– To Improve sensory function

 Interventions
 Positioning hemiplegic side towards door or main part of room
 Sensory Integration Therapy - Presentation of repeated sensory
stimuli
 Stretching, stroking, superficial & deep pressure, iceing, vibration etc.
 Wt bearing ex & Joint approximation tech
 Stoking with different texture fabrics
 Pressure application
 Improve other senses like use of visual & auditory
– To improve flexibility & joint integrity

 Interventions
 Soft tissue, joint mobilization & ROM exercise
 AROM & PROM with end range stretch
 Effective positioning & edema reduction
 Stretching program & splinting
– To improve strength
 Interventions
 Strengthening of agonist & antagonistic muscle
 Graded ex program using free weights, therabands, sand bags &
isokinetic devices
 For weak patients (<3/5), gravity-eliminated ex using powder
boards, sling suspension, or aquatic ex is indicated
 Gravity-resisted active movts are indicated (>3/5 strength)
– Manage spasticity
 Interventions
 Roods Approach

Sustained stretch & slow iceing of spastic muscle

Weight bearing exercise
Prolonged & firm pressure application
Slow rocking movement
 PNF –

Rhythmic rotations
Rhythmic initiation
– Improve balance and locomotion
 Interventions
 Balance
 Facilitate symmetrical wt bearing on both side
 Postural perturbations can be induced in different positions
 Sit or stand on movable surface to increase challenge
 Reaching activities
 Locomotion
 Initial gait training between parallel bars
 Proceed outside bars with aids & then without aids
Thank You