A Case Study Of A L Ischemic MCA Stroke

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. …show more content…

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
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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

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