L Ischemic MCA Stroke Case Studies

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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…
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
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TUG: (2 min 42 secs)
Pt is min Ax1 with quad cane.

10 M Walk: (2 min 40 secs)
Pt is min Ax1 with quad cane. Pt was 3ft short of completing the 10M due to severe R hip pain and being unable to tolerate WBing any longer.

Balance:

EO: 25.53 secs (Minimal Sway) Increased WB on L LE
EC: 21.60 secs (Mild Sway) Increased WB on L LE
Tandem R/L: Unable to get into position

(IMPAIRMENTS OF BODY STRUCTURE/FUNCTION) Cranial Nerves:
CN II: n/t 2° to expressive aphasia
CN III, IV, VI, VII: intact
CN XI: impaired on R Sensation:
Light Touch:
R/L UE & LE: Intact
R/L Sole of Foot: Impaired (Painful Sensation R>L)

Proprioception: Unable to be tested 2° to confusion/frustration with instructions

UE AROM: Pt’s L UE is WFL. Pt’s R UE wasn’t assessed due to him reporting R shoulder pain/soreness at rest; no subluxation

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