Saint Mungo's

Physical Thearpy Initial Evaluation

Outpatient Neuro Setting​

​

NAME: James Krum 

MRN: H07311980

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

​

SUBJECTIVE: 

Patient presents to outpatient physical therapy as continuation of rehabilitation post-stroke. Patient reports that he went to the hospital due to few day history of left arm weakness and a fall. Patient hospitalized from October 2nd to October 5th with diagnosis of right middle cerebral artery stroke, then transitioned to inpatient rehabilitation with discharge to home on November 1st. Patient reports that things are going well at home. Patient reports that he forgot about his appointment for outpatient therapy on November 6th, but feels like he has kept busy doing his occupational therapy home exercise program the past 1.5 weeks. His brother has been living with him and providing 24/7 assistance with all transfers and mobility. They are utilizing a standing pivot disk (Orbiturn) for transfers. Currently using a commode for toileting and sponge bathing until brother is able to widen doorframe into bathroom. Staying on main level of house in guest bedroom, purchased bed railing to assist with bed mobility. Able to enter/exit home with use of portable ramp that family rented. Has had 1 fall since being at home, which occurred when transferring into the passenger side of his brother’s truck when leaving the house to go to church - states that left leg “got stuck and went down.” Denies injury or hitting his head. Brother and son were able to lift patient from ground back to the seat of the truck. Since then, has been using their car for transportation which has been working better. Patient reports back pain since stroke that increases when he has been sitting in his wheelchair for several hours. He has been utilizing lidocaine cream to help manage. Patient has a family friend, who is a nurse, come over two days a week to assist with sponge bathing. Brother is assisting with range of motion and stretching to his left arm and leg. Patient reports that his goal is to “walk and use my left arm again.” 

 

• Functional Limitations: requires assistance for all transfers, unable to ambulate, requires ramp to enter/exit home, requires assistance for community mobility 

• School/Occupation/Hobbies: driving instructor for CDL classes, owns dairy cows that he was tending to prior to stroke, drives motorcycle, shoots pool, play with 5 month old grandson 

• Home Environment: resides in a 2 story home with portable ramp to enter through garage. Adult son permanently lives with patient but works during the day, brother is also staying with patient right now to assist.

• Prior level of function: active and independent without physical limitation prior to stroke

• Comorbidities/Complexities: Hypertension, CAD, hyperlipidemia, depression, smoking

• Review of Systems: positive for weakness, all other areas within normal limits

​

​

 OBJECTIVE:

Vitals

• Blood Pressure: 132/84

• Heart Rate: 78 bpm

• SpO2: 98%

​

Cognition

• Mental status: 11/15 on Brief Interview for Mental Status (required cuing for 2 out of 3 words for delayed word recall and unable to recall 1 word even with cues)

• Orientation: oriented x 4

• Ability to follow commands: able to follow 1 step commands with 100% consistency, able to follow 2 step commands with 50% consistency 

• Clock draw test: draws a complete circle, puts numbers 1-6 in correct orientation, but to left side of clock only puts 7 and 8 spaced out excessively 

• Comments: left inattention noted during functional mobility tasks, requiring cuing ~50% of the time to manage left side of wheelchair 

​

​

Vision

• Wears glasses for distance only at baseline

• Denies diplopia or blurred vision

• Visual fields: inaccurately reports < 25% targets in left visual field in both right and left eyes, increased time taken to recite numbers in left visual field. Right visual field in both eyes within normal limits

• Ocular range of motion: within normal limits

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

• Saccades: horizontal and vertical saccades demonstrates slowing to left > right 

• Convergence: 1 out of 3 reps neither eye converges, 2 out of 3 reps both eyes begin to converge but then right eye drifts laterally

 

​

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 40% of reps, ankle joint proprioception 60% of reps. Denies paresthesia. 

​

​

Balance

• Sitting: sits unsupported at edge of mat table without trunk lean, completes seated modified functional reach with right upper extremity - forward = 21.5 cm

• Standing: maintains standing with right single upper extremity support with standby assistance at railing, no knee block necessary for static stance. Able to release upper extremity support and maintain unsupported stance for 12 seconds. Standing with use of hemi-walker requires anywhere from standby assistance to minimum assistance for forward weight shift due to posterior instability.

​

​

Musculoskeletal

• Passive Range of Motion

  • Right lower extremity achieves neutral hip extension and knee extension, 5 degrees ankle dorsiflexion

  • Left lower extremity: lacks 5 degrees from neutral hip extension, lacks 5 degrees from neutral knee extension, lacks 12 degrees from neutral ankle dorsiflexion

• Strength

  • Right lower extremity 

    • Hip flexion: 5/5

    • Hip abduction: 5/5

    • Hip external rotation: 5/5

    • 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: 2+/5

    • Hip abduction: 2/5

    • Hip external rotation: 1/5

    • Hip internal rotation: 1/5 

    • Knee extension: 3-/5

    • Knee flexion: 2-/5 (tested in sitting)

    • Ankle dorsiflexion: 1/5

    • Ankle inversion: 1/5

    • Ankle eversion: ⅕

• Flexibility

  • Right lower extremity: moderate tightness noted into the hip flexors and hamstrings

  • Left lower extremity: significant tightness into the hip flexors, hamstrings, and gastrocnemius 

​

​

Neurologic

• Tone 

  • Right lower extremity: within normal limits

  • Left lower extremity: spasticity noted

    • Hip adductors: MAS 1+

    • Knee extensors: MAS 3

    • Ankle plantarflexors: MAS 3 

• Clonus

  • Right lower extremity: within normal limits

  • Left lower extremity: sustained clonus (20+ beats)

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

​

Functional Mobility

• Bed mobility: rolls to left side independently, requires minimum assist to roll to right. Completes supine to/from sit with contact guard assistance, primarily requiring tactile cuing to attend to left upper and lower extremity and ensure safety when close to edge of mat table. Utilizes right lower extremity to help manage left lower extremity.

​

• Transfers: completes wheelchair to mat table transfer with use of standing pivot disk with external arm support, pulling to stand with right upper extremity with contact guard assistance and assistance to stabilize pivot disk. Transfers sit to stand from manual wheelchair with minimum assist of 1 for forward weight shift and minimum assist for left knee block. Completes a squat pivot transfer mat table to wheelchair toward left side with maximum assist of 1. 

​

• Ambulation: ambulates along railing with right upper extremity support utilizing left posterior leaf spring ankle foot orthosis, tubigrip placed over forefoot of shoe. Requires moderate assistance to advance left lower extremity and to block left knee during stance to prevent buckling. Completes 15 foot distance, then able to retro ambulate ~2 feet along railing until loss of balance posteriorly requiring maximum assistance to recover/sit safely in manual wheelchair. Gait quality - excess left pelvic retraction, left lower extremity in extensor synergy, hip hiking and circumduction noted, no active knee flexion noted throughout gait cycle. 

​

• Stairs: not yet safe to attempt

​

• Wheelchair mobility: able to manage wheelchair leg rests and brakes independently with attachment to left brake, requires cuing ~50% of the time to appropriately manage leg rests and brakes, though. Can wheel short functional distances in gym utilizing right upper and lower extremity, but requires assistance of brother to navigate large, novel environment of the clinic in the community. 

​

​

Functional Outcome Measures

• Postural Assessment Scale for Stroke: 19/36

• Berg Balance Test: 6/56

• Gait speed: 0.029 m/sec timed over 10 foot distance along railing 

• Promis Physical Function: 21.6

• Stroke Impact Scale: see electronic health record for scanned document, note that brother assisted with intake

 

Signed by: George Black, DPT 11/16/24

​​​

​