Case presentation

1. Case Presentation 2
VISHNU VARDHAN S
RA2122204010004
MPT I YR ORTHOPAEDICS
17.09.2021

2. Demographic Data
► Full Name : Mr. Jagannathan
► Age : 50 years
► Gender : Male
► Dominance : Right
► Ward : Neurology
► UHID No. - 2153937
► IP No. - 2129096

3. ► Chief complaints :
►Difficulty in moving the left side of the body
►Difficulty in performing ADLs
►Difficulty in walking.

4. ► Past history :
► Past Medical – HTN since 3 years
► Past Surgical – None
►Family history : none
►Personal history :
► Appetite – Reduced
► Sleep – Disturbed
► Narcotic addiction - None
► Alcohol addiction - None
► Bowel – Normal
► Bladder – Normal
► Socioeconomic history :
► Kuppuswami Scale

5. Physical Examination
► General Examination :
►Blood pressure : 130/85 mmHg (Assuming based on atherosclerosis)
►Temperature : 99.2 F (Assuming based on complaint of fever)
►Pulse rate : 72 beats/min
►Respiratory rate : 19 breaths/mi
► Systemic Examination :
► On Observation
►Built : Endomorphic
►Nutrition : Mixed
►Pallor : Absent
►Icterus : Absent
►Oedema : Absent
►Attitude of the Patient : Supine lying

6. ► On Observation :
► Posture and Gait : (with support)
- Shoulders protracted
- Chin protruded
- Hip in external rotation
- Hyperextension of knee
- Inversion of foot
Gait – Circumductory gait
► On Palpation :
► Clubbing : Absent
► Cyanosis : Absent
► Oedema : Absent
► Tenderness : Absent

7. Nervous System Examination
► Higher Mental Function
► Coordination : Cannot be assessed
due to weakness
► Communication – Affected (slurred speech)

8. ► Cranial Nerve Assessment
► CN I - Sense of smell in each nostril
► CN II –
► Acuity of vision
► Field of vision
► Color vision
► CN III, IV, VI - External Ocular Movements
► CN V - Sensations over the face, Corneal, Conjunctival, Jaw Jerk ○
► CN VII - Expressions
► CN VIII - Rinne’s test, Weber’s test
► CN IX, X – Uvula “Ah” , Gag reflex
► CN XI - Trapezius, Sternocleidomastoid
► CN XII - Protrude tongue
► Involuntary Movements - Absent

9. Motor System Examination
►Range of Motion :
►Active Rom reduced on the left side
►Passive Rom Full
►Tone :
►Left side – 1+

10. ►Power :
►MMT –
►Left – 2/2+
►Right - 4

11. Reflexes
► Superficial
► Plantar - +
► Abdominal - +
► Deep
► Biceps - +
► Triceps - +
► Supinator - +
► Knee - +
► Ankle - +

12. Sensory System Examination
► Superficial Senses
► Touch - Diminished on the Left side
► Temperature - Diminished on the Left side
► Pain - Diminished on the Left side
► Deep Senses
► Position - Diminished on the Left side
► Joint sense - Diminished on the Left side
► Vibration - Diminished on the Left side
► Cortical Senses
► Tactile Localization - Diminished on the Left side
► Tactile Discrimination - Diminished on the Left side
► Stereognosis - Diminished on the Left side

13. ►Investigations
►CT scan shows ( RT ) middle cerebral artery infarct
►Diagnosis
►Medical Diagnosis – Right Middle Cerebral Artery
Infarct
►Physiotherapy Diagnosis – Inability to use the left
side of the body and weakness secondary to right
MCA infarct.

14. Problem List
► Tonal abnormalities
► Muscular weakness
► Functional disability
► Possible Problems in Post Stroke
► Synergistic pattern
► Tightness & contracture
► Imbalance & incoordination
► Gait abnormalities
► Postural abnormalities
► Deconditioning

15. Goals
► Short Term(Acute Phase)
► To make the patient
aware about the
status of his condition
► Improve respiratory &
circulatory function
► Prevention of
secondary
complications
► Prevent from
deconditioning
Long Term(Sub-Acute and Chronic Phase)
Maintain all short term goals
Improve sensory function
Flexibility & joint integrity
Improve strength
Manage spasticity
Improve motor control
Improve upper extrimity
function
Improve balance
Improve locomotion
Improve aerobic function
Discharge planning

16. Management :
G – To Improve respiratory & circulatory
function
► Interventions
► Breathing exercise
► Chest expansion exercise
► Postural drainage
► Huffing & Coughing techniques
► Passive & active ankle & toe exercise
►(after careful & thorough examination of
cardiopulmonary system)

17. G – To Prevent of pressure s
► Interventions
► Proper positioning
► Relieve pressure points by padding & cushion
► Frequent turning & changing position
► Prevent from moisture
► Tight fitting cloth to be avoided
► Use of waterbed, air bed & foam mattress

18. G – To Improve sensory function
► Interventions
► Positioning hemiplegic side towards door or main part of
room
► Sensory Integration Therapy - Presentation of repeated
sensory stimuli
► Stretching, stroking, superficial & deep pressure, iceing,
vibration etc.
► Wt bearing ex & Joint approximation tech
► Stoking with different texture fabrics
► Pressure application
► Improve other senses like use of visual & auditory

19. G – To improve flexibility & joint integrity
► Interventions
► Soft tissue, joint mobilization & ROM exercise
► AROM & PROM with end range stretch
► Effective positioning & edema reduction
► Stretching program & splinting

20. G – To improve strength
► Interventions
► Strengthening of agonist & antagonistic muscle
► Graded ex program using free weights, therabands,
sand bags & isokinetic devices
► For weak patients (<3/5), gravity-eliminated ex using
powder boards, sling suspension, or aquatic ex is
indicated
► Gravity-resisted active movts are indicated (>3/5
strength)

21. G – Manage spasticity
► Interventions
► Roods Approach
►Sustained stretch & slow iceing of spastic muscle
►Weight bearing exercise
►Prolonged & firm pressure application
►Slow rocking movement
► PNF –
►Rhythmic rotations
►Rhythmic initiation

22. G – Improve balance and locomotion
►Interventions
►Balance
►Facilitate symmetrical wt bearing on both side
►Postural perturbations can be induced in different
positions
►Sit or stand on movable surface to increase challenge
►Reaching activities
►Locomotion
►Initial gait training between parallel bars
►Proceed outside bars with aids & then without aids

23. Thank You