Case Analysis : Pt 's Current Functional Limitations Essay

1611 Words Oct 1st, 2016 7 Pages
Diagnosis: Pt is a 54 yo male who experienced a L ischemic MCA stroke and as a result, has functional limitations as well as expressive aphasia. The majority of pt’s current functional limitations are due to slow recovery from an ORIF of R Hip approximately 3 months ago. Chief Complaint: Pt experienced a L ischemic MCA stroke on the morning of 8/20/2014 which has negatively impacted motor function on R side and his ability to produce speech. Most recently on 07/10/16, pt twisted his R knee which led him to fall in his house which then resulted in a R hip fracture and underwent ORIF surgery. Pt received PT for his R hip however, ambulation is still significantly limited due to severe pain and decreased WB through R LE since his fall. Pt went to the ER on 8/22/16 because of severe R hip pain as well as R knee pain. X-Rays were taken of the whole R LE at this time and all radiographs came back negative according to pt’s wife. Pt also had an ultrasound in order to rule out possible DVT; results were negative. Pt was prescribed Gabapentin as well as Magnesium and was then discharged back home from the ER. Pt’s wife states the injury/surgery on his R hip has really been a setback for him. Prior to this setback, pt was only relying on a w/c for traveling long distances and was also able to ascend/descend stairs. Health Condition: (Medical/Surgical History): Prior to CVA, pt was diagnosed with type 2 diabetes and neuropathy. Past surgeries include; R carotid…

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