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Saint Mungo's Hospital

Physical Thearpy Initial Evaluation

Acute Care Setting

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NAME: James Krum 

MRN: H07311980

AGE: 64 year old               DOB: 12/25/1960

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SUBJECTIVE: 

Patient reports that his back hurts from the MRI earlier today, and it is hard for him to move the left side of his body in bed. States that he has been passing his time in his hospital room by talking with family on the phone and playing games on his iPad. Rates his back pain at a 6/10, nursing has been giving him a hot pack to manage. He shares that he hasn’t been up out of bed at all since the code stroke was called yesterday. Reports desire to discharge home from hospital and is looking forward to physical therapy in helping him “get back to normal.” 

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Precautions: fall risk 

Lines/Drains/Airways: IV and Telemetry 

Usual Living Arrangement:

  • Lives with: adult child

  • Discharge Support System: adult son who works during the day. Daughter is currently living 2 hours away while attending college. Does have a few other siblings and friends who live locally, but does not see them on a regular basis.

  • Usual Living Arrangement: 2 story house, bedroom is on the second level. Full bathroom on each level. 

  • Steps to enter home:  2 steps with single railing ascending on right

  • Bathroom setup: walk-in shower, grab bars, raised toilet, shower chair

  • Durable medical equipment owned: none

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 Prior Level of function:

  • Activities of Daily Living: independent

  • Instrumental Activities of Daily Living: independent, responsible for his yard work including snow removal

  • Prior mobility status: independent, without use of adaptive equipment or assistive devices

  • Job Status: retired truck driver, but continues to work part-time. Owns several dairy cows and teaches commercial driver’s license courses on the weekend at a local community college.

  • Falls in the past year: yes – reason for hospitalization, occurred due to a trip while going up the stairs 

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Other:

  • Patient denies previous participation in physical therapy and residual deficits following concussion and TIA

  • Reports that his knee pain has not caused him any pain/difficulty recently, his knees mostly hurt when he was still working full-time as a truck driver

  • Reports being right-hand dominant

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 OBJECTIVE:

Cognition

  • Mental status: 11/15 on Brief Interview for Mental Status (2 out of 3 immediate word recall, required cuing for 2 out of 3 words for delayed word recall, and did not recall the day of the week)

  • Orientation: oriented x 3 (unable to recall day of the week)

  • Ability to follow commands: fair.

  • Comment: requires consistent cuing 100% of the time to attend to left upper extremity placement with transfers. Requires cuing 100% of the time to turn head to left to locate clock in room when writer asks patient the time. Lacks insight into deficits

Communication

  • No deficits

Vision

  • Wears glasses for distance only at baseline, eyewear not present at hospital. Reports being scheduled to see ophthalmologist for a repeat eye exam due to risk for diabetic retinopathy.

  • Denies diplopia or blurred vision

  • Unable to correctly read clock on wall and required cuing to locate it as it was positioned to his left. Able to read therapist’s name badge accurately.

  • Left visual field impaired, reduced range with smooth pursuits and saccades horizontal to the left, with cuing able to improve with pursuits but not saccades.

Sensation

  • Light touch sensation within normal limits to right lower extremity, intact but dull proximal to left ankle but absent below ankle and at foot. 

  • Reports tingling into left lower extremity proximal to left ankle, numbness below. Denies paresthesia into right lower extremity.

Balance

  • Sitting: requires minimum assistance to sit at edge of bed unsupported due to left lateral trunk lean, with right upper extremity support can sit with close standby assistance

  • Standing: requires maximum assistance of 1 on left and moderate assistance of 1 on right at gait belt to maintain static standing posture, assist on left for left knee block and to provide support to upper extremity. Right upper extremity support on large-based quad cane with posterior stabilization of lower extremities against the hospital bed.

Musculoskeletal

  • Right and left lower extremity range of motion within functional limits passively

  • Right lower extremity range of motion within functional limits actively

  • Left lower extremity active range of motion (noted significant posterolateral lean to left with assessment at edge of bed, therefore, completed some testing in supine)

    • Hip flexion: trace muscle activation in sitting, did not assess in sidelying

    • Hip abduction: initiates very small range (<10% available range) in supine

    • Knee extension: achieves ~initial 30% of available range

    • Knee flexion: trace muscle activation in sitting, did not assess in sidelying

    • Ankle dorsiflexion: trace muscle activation

  • Right upper extremity active range of motion within functional limits, left upper extremity flaccid

Neurologic

  • Tone: decreased muscle tone to left lower extremity, Modified Ashworth 0/4 throughout bilateral lower extremities

  • Coordination: unable to assess toe tapping or heel to shin due to weakness on left lower extremity, right lower extremity within functional limits

  • Clonus: absent at bilateral ankles

Cardiovascular

  • Vitals during session

  • Supine in bed prior to mobility: 146/89 mmHg, heart rate 72 bpm, SaO2 98%

  • Sitting edge of bed: 119/78 mmHg, heart rate 78 bpm, SaO2 98%. Mild dizziness noted upon transition to edge of bed sitting that resolves within 2 minutes.

  • Activity tolerance: fair

Functional Activities:

  • Bed mobility- requires maximum assistance at left lower extremity to mobilize toward edge of bed (right side of bed), maximum assistance manage left upper extremity during task, maximum cuing for sequencing and pushoff through right upper extremity to right trunk during task also requiring moderate assistance from writer for supine to sit. Sit to supine requires maximum assistance at left lower extremity and trunk, able to scoot self laterally in bed a small amount with maximum assistance to flex left/hip and stabilize for scoot and cuing for appropriate sequencing/positioning. Able to roll to left with standby assistance and verbal cuing to locate bed rail, roll to right with maximum assistance.

  • Transfers- requires handheld assistance/support at left upper extremity, maximum cuing and assistance for left knee flexion to obtain appropriate base of support for sit to stand transition, and left knee block with moderate assist of 2 using large-based quad cane. Maintains static standing for 35 seconds to maximum tolerance. Unable to progress to pivot transfer due to inability to offload either lower extremity in standing despite moderate assistance of 2.

Outcome Measures:

  • Postural Assessment Scale for Stroke: 9/36

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Electronic signature: Ginny Trelawney, DPT 10/4/2024

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