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.
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OBJECTIVE: SYSTEMS REVIEW
Cardiopulmonary System: Blood Pressure: 125/70mmHg (sitting/L UE) Heart Rate: 82bpm (strong/regular) (L radial pulse)
Respiratory Rate: 18bpm
O2 Sat: 99% (at rest/L 3rd digit), 97% (post 10M walk)
CTT: unable 2° expressive aphasia Integumentary System: Intact, no skin breakdown. Scars consistent with bilateral carotid endarterectomy were noted. R LE discoloration (purple/red) with minimal edema compared to the L LE was observed. Neuromuscular and Musculoskeletal System: impaired, detailed examination below.
Communication, Affect, Cognition: Pt is able to follow simple, straight forward commands. Pt’s writing is difficult to read since he was R hand dominant prior to L CVA. Pt can say basic phrases such as yes, no, and I don’t know. Pt presents with flat affect and tends to get frustrated easily when attempting to communicate or express himself.
Trail Making Test: (59 secs) (Average: 29 secs) (Deficient >78 secs) pt made two errors but, knew immediately and quickly corrected those …show more content…
Pt presents with an antalgic gait, limited endurance, slow gait speed, narrow BOS, and minimal kyphotic posture. He puts approximately 90% of his BW through the L LE and also puts a significant amount of pressure through quad cane using his L UE. Touch-down WB on R LE was observed as well as, significant decreased stance time on the R. He experiences most difficulty with the lateral weight shift from L to R foot due to R hip pain. Pt also has limited hip flexion, hip extension, and knee extension ROM on the R therefore, affecting trailing limb position as well as swing phase and loading response. No muscle contractions were felt in pt’s R LE in sitting and gravity minimal positions weren’t tolerated due to R hip pain. Therefore, R LE muscle weakness is most likely playing a major role in his decreased stance time and ability to WB on
OBJECTIVE: SYSTEMS REVIEW
Cardiopulmonary System: Blood Pressure: 125/70mmHg (sitting/L UE) Heart Rate: 82bpm (strong/regular) (L radial pulse)
Respiratory Rate: 18bpm
O2 Sat: 99% (at rest/L 3rd digit), 97% (post 10M walk)
CTT: unable 2° expressive aphasia Integumentary System: Intact, no skin breakdown. Scars consistent with bilateral carotid endarterectomy were noted. R LE discoloration (purple/red) with minimal edema compared to the L LE was observed. Neuromuscular and Musculoskeletal System: impaired, detailed examination below.
Communication, Affect, Cognition: Pt is able to follow simple, straight forward commands. Pt’s writing is difficult to read since he was R hand dominant prior to L CVA. Pt can say basic phrases such as yes, no, and I don’t know. Pt presents with flat affect and tends to get frustrated easily when attempting to communicate or express himself.
Trail Making Test: (59 secs) (Average: 29 secs) (Deficient >78 secs) pt made two errors but, knew immediately and quickly corrected those …show more content…
Pt presents with an antalgic gait, limited endurance, slow gait speed, narrow BOS, and minimal kyphotic posture. He puts approximately 90% of his BW through the L LE and also puts a significant amount of pressure through quad cane using his L UE. Touch-down WB on R LE was observed as well as, significant decreased stance time on the R. He experiences most difficulty with the lateral weight shift from L to R foot due to R hip pain. Pt also has limited hip flexion, hip extension, and knee extension ROM on the R therefore, affecting trailing limb position as well as swing phase and loading response. No muscle contractions were felt in pt’s R LE in sitting and gravity minimal positions weren’t tolerated due to R hip pain. Therefore, R LE muscle weakness is most likely playing a major role in his decreased stance time and ability to WB on