Professional Documents
Culture Documents
Case Con (1) - 1
Case Con (1) - 1
HPI
14 years PTIE
Pt was at home with his wife and suddenly complains of dizziness and told his wife to bring him
to the hospital but his wife didn’t believe him and proceeded to the bathroom and took a shower
then suddenly his wife heard a rumble and saw her husband unconscious in their bed she
immediately called an ambulance and after 30 mins the ambulance arrived and the Pt was
rushed to The medical city and was admitted into the ICU for 8 days and was diagnosed to have
CVD (brainstem) PT management was initiated in the ICU then after 8 days Pt was transferred
to a regular room and stayed there for 1 month and PT managements were continuously done
after that the Pt was discharged and continued receiving home PT services for the next 6 mos
2x a week. Pt is unable to work and is dependent in all aspects of ADLs such as self-care,
mobility, transfers and ambulation.
13 years PTIE
Pt’s wife decided to bring the Pt back to Hospital Based PT treatment since her wife noticed little
to no improvements. PT continuously received PT treatment for 8 years in The Medical city. Pt is
still unable to work and is dependent in all aspects of ADLs such as self-care, mobility, transfers
and ambulation.
5 years PTIE
Pt’s wife decided to transfer him to camilos PT clinic where the Pt continued PT treatment for 4
years. Pt is still unable to work and is dependent in all aspects of ADLs such as self-care,
mobility, transfers and ambulation.
3 years PTIE
Pt was discharged from the PT clinic and was prescribed home PT services in tagaytay and
continued it for 2 years. Pt is still unable to work and is dependent in all aspects of ADLs such
as self-care, mobility, transfers and ambulation.
1 week PTIE
Pt’s wife decided to bring him back to a hospital based PT clinic because she noticed that the
patient was regressing and she felt that the home care was not really effective.
At Present
Pt is unable to work and is dependent in all aspects of ADLs such as self-care, mobility,
transfers and ambulation.
PMHx
(+) HTN
(+) Surgery (gall stones removal)
(+) asthma
(-) DM
(-) cancer
(-) OA
(-) RA
FMHx
MATERNAL PATERNAL
DM (+) (-)
CA (-) (-)
OA (-) (-)
PSEHx
Personal
- Prefers to eat fast food and meat
- Pt loves to read a lot
- Hobbies includes watching tv and listening to music
- Pt has no sleep disturbances
- Pt wears diaper
GENERAL SURVEY
● W/C borne
● Ectomorph
● (+) typical arm posture on (B) UE (SH adducted, elbow flexed, wrist flexed and wrist
ulnar deviated and finger flexed)
● (+) cortical thumb on (B) UE
● (+) SH subluxation on (L) UE
● (+) Postural Deviation
● (-) swelling on (B) UE and LE
● (-) edema on (B) UE and LE
Vital signs
a p
T⁰ afebrile afebrile
Int: Pt has high BP at baseline and p treatments
Sig: For baseline purposes and treatment precautions d/t pt having (+) HTN
SKIN
● Normal skin turgor, mobility and Consistency
● Normothermic on (B) UE and LE
● (-) discolorations on (B) UE and LE
● (-) wounds on (B) UE and LE
● (-) bruise on (B) UE and LE
EXTREMITIES
● (+) grade 2 Spasticity on (B) UE
● (+) deformity on (B) UE and LE
● (+) crepitus on the ® knee
● (+) (L) shoulder subluxation (2 finger breaths)
● (-) tenderness on (B) UE and LE
NEUROLOGICAL EXAMINATION
Mental Status
● Alert (100%) coherent (50%) cooperative (80%)
● Pt communicates through eye and eyebrow movements
● Pt is able to follow simple commands
Tone Assessment
Tone of (B) UE were assessed using Modified Ashworth Scale and are (N) findings
except for:
Elbow Flexors 2 2
Knee extensors 1+ 1+
Knee flexors 1+ 1+
Ankle plantarflexors 1+ 1+
Int: patient has spasticity on (B) elbow flexors, knee extensors, knee flexors, and ankle
plantarflexors
Sig.: Pt’s condition is indicative of an UMNL. This also indicates a poor prognosis because pt
still presents c spasticity s/p stroke 14 yrs ago
Legend:
GRADE DESCRIPTION
0 No ↑ in muscle tone
4 Rigid
Sensory Evaluation:
Superficial Sensation
STD: Dull end for deep pressure, pinprick for pain and brush for light touch
® (L)
Reflex Testing
Pathologic Reflex
CN Test Result
Olfactory Smelling of familiar intact
Scents
Optic Confrontation test Intact
Oculomotor, Trochlear, Saccadic and pursuit Intact
Abducens eye movement
Trigeminal Facial Sensation Not assessed
Muscles of
Mastication
Reflex Testing
Int: Pt presents c Hyperreflexia of (B) biceps and patellar tendon and clonus on (B) wrist .
Sig: Pt has Hyperreflexia of (B) biceps and patellar tendon, clonus on (B) wrist secondary to
UMNL.
ADL Analysis
*Used FIM
FIM
Eating 2
Grooming 1
Bathing 1
Dressing Upper Body 1
Dressing Lower Body 1
Toileting 1
Bladder Management 1
Bowel Management 1
Transfer 1
bed/chair/wheelchair
Transfer toilet 1
Transfer bath/shower 1
Locomotion 1
Stairs 1
Motor Subtotal Score 14/91
(max. score 91)
Comprehension 6
Expression 6
Social interaction 1
Problem solving 1
Memory 7
Cognition Subtotal Score 21/35
(max. score 35)
TOTAL FIM SCORE (max. 35/126
score 126)
Legend:
0-20 - unable/totally dependent
21-40 - extreme difficulty
41-60 - severe difficulty
61-80 - moderate difficulty
81-99 - mild difficulty
100 - no difficulty/totally independent
Postural Analysis
(done in supine)
All bony landmarks are WNA except:
Anterior and Posterior view Lateral view
(B) SH adducted, elbow flexed, FA pronated, External acoustic meatus is forward in relation
wrist flexed and finger flexed to the acromion process
(L) GH is lower in relation to the ®
(B) Hip flexed, adduced and IR (B) Knees are slightly flexed, ankle are
supinated
Int: Pt has (+) typical arm posture on (B) UE
Sig: Pt will develop further deviations if not corrected
PT Impression
Pt is dependent in all aspects of ADLs as such as, self-care, feeding, transfers, mobility, and
ambulation brought about by impaired muscle performance, (+) muscle spasticity, impaired joint
mobility, hyperreflexive, and (+) postural deviation secondary to s/p CVD brainstem
Prognosis
(+) (-)
Pt ‘s age
LTG
Pt will maintain current functional status as to prevention of secondary complications such as
DVT, contractures, edema and atrophy all throughout PT sessions
Plan Of Care
Problem STG POC
Potential Problems d/t ADL Pt will not present any ● Passive ankle pumps
dependency potential problems p 3 weeks x 10 reps x 1 set
● DVT of PT sessions ● Bed mobility exercises
● Contractures (supine to side-lying
● Edema and v.v.)
● Atrophy ● PROMEs of (B) UE
and LE x 10 reps
● Caregiver education
as to elevation of
● Supine to side-lying c
use of tactile cues and
assistance
● PNF pattern using D1
flexion of UE and LE