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Saint Mungo's Hospital - IRD Department

Physical Therapy Initial Evaluation

Inpatient Rehabilitation (Setting 2)

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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 he is excited to be in inpatient rehabilitation. Shares that he had a fall this morning, states that he thought he could make it safely to the bathroom but his left leg gave out. Denies any increased weakness or changes in cognition following. Shares that his therapy goals are to discharge home and walk. Notes that he has some low back and left knee pain following his fall, rating both at a 5/10. States that the nurse gave him Tylenol about 1 hour ago. 

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Precautions: fall risk

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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 in shower, raised toilet, built-in shower chair

  • Durable medical equipment owned: none

 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 – due to left-sided weakness day of hospital admission, occurred due to a trip while going up the stairs.

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OBJECTIVE:

Cognition

  • Mental status: 8/15 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 unable to recall 1 word even with cues, did not recall the day of the week, and inaccurate year)

  • Attention: 8-11 mm deviation to the right of midline on line bisection test 100% of reps

  • Orientation: oriented x 3 (disoriented to time - unable to recall day of the week or year)

  • Ability to follow commands: fair.

  • Comment: requires consistent cuing 100% of the time to scan for objects located on his left side during evaluation (ie: left wheelchair brake, room positioned on left side of hallway). Impaired safety awareness with tendency to initiate movement for transfer prior to writer being prepared/cuing patient to initiate a task.

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Communication

  • No aphasia, dysarthria, or word finding difficulties noted

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Vision

  • Wears glasses for distance only at baseline, wearing in room to watch television during time of physical therapy evaluation. 

  • Denies diplopia or blurred vision

  • Able to accurately locate and read digital clock on wall. 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.

  • Visual fields: unable to see or inaccurately reports ~75% targets in left visual field in both right and left eyes, right visual field in both eyes within normal limits

  • Ocular range of motion: left eye reduced lateral gaze and right eye reduced medial gaze, otherwise within normal limits.

  • Smooth pursuits: horizontal and vertical pursuits demonstrates mild saccadic intrusions

  • Saccades: horizontal demonstrates undershooting to left 100% of reps with slowing latter 50% of reps, vertical demonstrates slowing latter 50% of reps

  • Convergence: tendency for lateral gaze deviation to left eye 2 out of 3 reps, lateral gaze deviation to right eye 1 out of 3 reps. Does not report diplopia, unable to assess near point convergence.

  • Other: right gaze preference to both eyes at rest

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Sensation

  • Right lower extremity: within normal limits without paresthesia 

  • Left lower extremity: light touch sensation intact but dull at and proximal to left ankle, absent below ankle and foot. Pinprick sensation intact throughout left lower extremity with exception of dorsum surface of left foot. Great toe joint proprioception accurate 20% of reps, ankle joint proprioception 40% of reps. Denies paresthesia. 

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Balance

  • Sitting: requires minimum assistance to sit at edge of bed with right upper extremity support due to left lateral trunk lean about 20 degrees to the left of midline. With assistance of mirror, able to right trunk to about 10 degrees to the left of midline but only able to maintain for about 30 seconds. Demonstrates immediate posterolateral loss of balance to the left with attempt at sitting with right upper extremity supported in his lap. Able to sit edge of bed > 8 minutes.

  • Standing: requires railing use to pull to stand with right upper extremity, moderate assistance of 2 with left knee block and manual facilitation for hip/postural extension. Able to maintain for 15 seconds maximum with moderate assistance of 2 and left knee block.

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Musculoskeletal

  • Passive Range of Motion

    • Right lower extremity within functional limits 

    • Left lower extremity: within functional limits at hip/knee, lacks 5 degrees from neutral ankle dorsiflexion

  • Strength

    • Right lower extremity 

      • Hip flexion: 5/5

      • Hip abduction: 4/5

      • Hip external rotation: 4+/5

      • Hip internal rotation: 5/5

      • Knee extension: 5/5

      • Knee flexion: 5/5 (tested in sitting)

      • Ankle dorsiflexion: 5/5

      • Ankle plantarflexion: 5/5 (tested in sitting)

      • Ankle inversion: 5/5

      • Ankle eversion: 5/5

    • Left lower extremity 

      • Hip flexion: 1/5

      • Hip abduction: 1/5

      • Hip external rotation: 0/5

      • Hip internal rotation: 0/5

      • Knee extension: 1/5

      • Knee flexion: 0/5 (tested in sitting)

      • Ankle dorsiflexion: 0/5

      • Ankle plantarflexion: 0/5 (tested in sitting)

      • Ankle inversion: 0/5

      • Ankle eversion: 0/5

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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

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Cardiovascular

  • Vitals during session

    • Supine in bed prior to mobility: 138/86 mmHg, heart rate 80 bpm, SaO2 98%

    • Sitting edge of bed: 126/78 mmHg, heart rate 88 bpm, SaO2 98%. Asymptomatic of dizziness or lightheadedness.

  • Activity tolerance: fair

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Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Scores:

  • Bed mobility

    • Roll left and right: 2 (helper does more than half the effort)

      • Comments: requires maximum assistance to roll to right, standby assistance for locating bed rail and verbal cuing to roll to left pullin on bed rail with right hand

    • Supine to sit: 2 (helper does more than half the effort)

      • Comments: able to manage right lower extremity independently, but requires total assistance to manage left lower extremity and moderate assistance at his trunk, utilizes right upper extremity and head of bed elevation to assist with trunk righting (transfer out to right side of bed).

    • Sit to supine: 1 (helper does all the effort or 2 people are required to assist)

      • Comments: requires total assistance for left lower extremity management, maximum assistance plus additional person contact guard assistance at trunk, minimum assistance at right lower extremity (transfer into bed toward his left)

  • Transfers

    • Sit to stand: 1 (helper does all the effort or 2 people are required to assist)

      • Comments: requires railing use to pull to stand with right upper extremity, left knee block, and moderate assist of 2

    • Chair/Bed-to-chair transfer: 1 (helper does all the effort or 2 people are required to assist)

      • Comments: squat pivot transfer wheelchair to bed (level surface) with right upper extremity reaching for bed railing and armrest removed. Writer positioned anteriorly to patient providing left knee block and 2nd person providing support posteriorly to patient at trunk.

    • Car transfer: safety concerns/unable to attempt

  • Ambulation

    • Walk 10 feet: safety concerns/unable to attempt

    • Walk 50 feet with 2 turns: safety concerns/unable to attempt

    • Walk 150 feet: safety concerns/unable to attempt

    • Walk 10 feet on uneven surfaces: safety concerns/unable to attempt

  • Stairs

    • 1 step (curb): safety concerns/unable to attempt

    • 4 steps: safety concerns/unable to attempt

    • 12 steps: safety concerns/unable to attempt

  • Wheelchair Mobility

    • Wheels 50 feet: 3 (helper does less than half the effort)

      • Comments: requires assistance for locking/unlocking left wheelchair brake, removing the foot rest, and minimum assistance 50% of the time when turning to the right only. Verbal cues for attending to left side, patient utilizing right upper and lower extremity for propulsion.

    • Wheels 150 feet: 2 (helper does more than half the effort)

      • Comments: requires assistance for locking/unlocking left wheelchair brake, removing the foot rest, minimum assistance 75% of turns to the right, and assistance to complete the final 75 feet of wheelchair propulsion due to fatigue and very poor efficiency. Verbal cues for attending to left side, patient utilizing right upper and lower extremity for propulsion.

  • Other

    • Picking up object: safety concerns/unable to attempt

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Outcome Measures:

  • Postural Assessment Scale for Stroke: 8/36 

  • Berg Balance Test: 0/56

  • Timed wheelchair propulsion: requires 2 minutes to wheel 50 feet without turns, for speed of 0.13 m/sec​

 

Electronic signature: Susan Lockhart, DPT 10/6/2024​​​​

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