The document presents a case study of a 70-year-old female patient who experienced a stroke 7 years ago resulting in left-sided hemiparesis and weakness. She fractured her left hip in 2018 further limiting mobility. On examination, she has reduced range of motion, muscle weakness and spasticity on the left side. Her functional assessment score is 56/126. The diagnosis is left hemiparesis due to an ACA stroke. Short term goals are to prevent complications and long term goals are to improve strength, manage spasticity and increase upper extremity function through a home exercise program.

1. CASE PRESENTATION
PRESENTED BY - Mrigakshi Talukdar
MPT , 2nd Semester

2. 1. DEMOGRAPHIC DATA
 Name : Mrs. Sabita Saha
 Age : 70 years
 Sex : Female
 Address : Goalpara, Assam.
 Occupation : High school teacher
 Hand dominance : Right
 Date of examination : 3rd April 2023

3. 2. SUBJECTIVE ASSESSMENT
Chief complain: patient complaints of pain in the left side of the hip joint,
weakness in left hand and unable to stand and walk since 7 years.
History of Present illness : The patient was apparently alright 7 years before,
after that one day while going to the bathroom she started feeling dizziness and
fell down. She was immediately admitted to the Shillong hospital for some days,
there she was diagnosed with stroke. After that she had weakness on the left side
of the body along with difficulty in the movements.
The patient also have a history of fall and had a fracture of hip on 8th September
2018 which lead to restricted movements of the lower limbs. The patient was
admitted to Sacred Heart Palliative Care on 9/10/2020 by her brother in law.
Past medical history : Hypertension since 15 years
Type 2 diabetes since 15 years

4. Medication history : tab glyciphage 500mg , tab eslo tel
Surgical History : present (fracture of proximal femur bone.)
Family history : 1 daughter
Bread winner – daughter
Marital status - widow
Environmental history : not significant
Socioeconomic status : lower middle class
Personal history
Diet : non veg
Appetite : normal
Sleep : disturbed
Bowel/bladder : regular
Habit : not significant

5. Objective assessment
Vitals
Pulse rate – 80 bpm
Respiratory rate – 19 bpm
Blood pressure – 150/90 mm Hg
On observation
Attitude of the patient – Supine lying
Attitude of limb – hip and knees are slightly flexed and
ankle is slight dorsiflexed.
Facial expression- discomfort

6. Swelling – absent
Deformity – flexion deformity
Built – mesomorphic
Gait- unable to walk.
Mode of ventilation- independent
On palpation
Tenderness – grade 1 (over the left hip)
Oedema – absent
Warmth – normal

7. Pain assessment :
Onset : gradual
Duration : since september 2018
Pattern : intermittent pain
Character : dull aching
Site : lateral aspect of the hip
Side : left
Aggrevating factor : lying on affected side , sitting more than 2-5
minutes.
Relieving factors : supine lying , medicine
VISUAL ANALOGUE SCALE (VAS) : On activity : 6
on rest : 4

8. ON EXAMINATION

9. Sensory Examination
• SUPERFICIAL -
• pain - intact
• temperature - intact
• touch - intact
• DEEP SENSATION -
• propioception- intact
• kinesthesia- intact
• 2 point discrimination - intact

10. CRANIAL NERVE EXAMINATION
• CN 1 (olfactory) – Intact bilaterally
• CN 2(optic) – intact bilaterally
• CN 3,4,6 ( oculomotor, trochlear, abducent) – intact bilaterally
• CN 5 (trigeminal) – intact
• CN 7(facial) – intact
• CN 8(vestibulocochlear) – intact at right side
• CN 9 (glossopharyngeal) – not significant
• CN 10 ( vagus) - intact
• CN 11 (accessory) – intact bilaterally
• CN 12(hypoglossal) – slightly deviated

11. On Examination : ROM(upper limb)
JOINTS RIGHT JLEFT
SHOULDER FLEXION ACTIVE (0-120), PASSIVE (0-128) ACTIVE (0-87), PASSIVE (0- 95)
SHOULDER EXTENSION ACTIVE (0-42), PASSIVE (0-45) ACTIVE (0-20), PASSIVE (0- 26)
SHOULDER ABDUCTION ACTIVE (0-110), PASSIVE (0-120) ACTIVE (0-85), PASSIVE (0-90)
SHOULDER ADDUCTION ACTIVE (110-0), PASSIVE (120-0) ACTIVE (85-0),PASSIVE (90-0)
SHOULDER INTERNAL ROTATION ACTIVE (0-40), PASSIVE (0-45) ACTIVE (0-20), PASSIVE (0-23)
SHOULDER EXTERNAL ROTATION ACTIVE (0-45), PASSIVE (0-52) ACTIVE (0-20), PASSIVE (0-28)
ELBOW FLEXION ACTIVE (0-140), PASSIVE (0-145) ACTIVE (0-110), PASSIVE (0-115)
ELBOW EXTENSION ACTIVE (140-0), PASSIVE (145-0) ACTIVE (110-0), PASSIVE (115-0)
FOREARM SUPINATION
FOREARM PRONATION
Not significant
Not significant
Not significant
Not significant
WRIST FLEXION
WRIST EXTENSION NOT SIGNIFICANT NOT SIGNIFICANT

12. JOINTS RIGHT LEFT
HIP FLEXION
HIP EXTENSION
HIP ABDUCTION
NOT SIGNIFICANT NOT SIGNIFICANT
KNEE EXTENSION
KNEE FLEXION
NOT SIGNIFICANT
0- 45
NOT SIGNIFICANT
0-44
PLANTAR FLEXION
DORSIFLEXION
NOT SIGNIFICANT NOT SIGNIFICANT
Tone – hypertonia (spasticity)
Grading of spasticity – 1 (by modified ashworth scale)

13. Manual muscle testing (MMT)
UPPER LIMB (Within available range)
MUSCLES RIGHT LEFT
SHOULDER FLEXORS GRADE 4+ GRADE 3+
SHOULDER EXTENSORS GRADE 2 GRADE 2-
SHOULDER ABDUCTORS GRADE 5 GRADE 4-
SHOULDER ADDUCTORS GRADE 4- GRADE 4-

14. MUSCLES RIGHT LEFT
SHOULDER INTERNAL
ROTATORS
GRADE 4+ GRADE 3+
SHOULDER EXTERNAL
ROTATORS
GRADE 4+ GRADE 3+
ELBOW FLEXORS GRADE 4+ GRADE 4-
ELBOW EXTENSORS GRADE 5 GRADE 4
WRIST FLEXORS
WRIST EXTENSORS
GRADE 4-
GRADE 4
GRADE 4-
GRADE 4-

15. MUSCLE RIGHT LEFT
HIP FLEXION GRADE 3- GRADE 3-
HIP EXTENSION Not significant Not significant
HIP ABDUCTORS GRADE 2- GRADE 2-
HIP INTERNAL ROTATION
HIP EXTERNAL ROTATION
Not significant Not significant
KNEE FLEXORS
KNEE EXTENSORS
GRADE 2- GRADE 2-
ANKLE PLANTAR FLEXORS Grade 2 Grade 2
ANKLE DORSIFLEXORS Grade 3- Grade 3-
Reflex-
SUPERFICIAL PLANTER- Babinski sign positive
DEEP TENDON REFLEX-
Knee jerk – absent bilaterally, grade 0
Ankle jerk – present bilaterally , grade 2

16. Coordination test
Non equilibrium test
• Finger to nose – 4(R), 2(L)
• Finger to finger – 4(R), 2(L)
• Finger opposition – 4(R), 3(L)
• Drawing a circle (hand) –4(R),3(L)
• Drawing a circle (foot) – 2(R,L)
• Heel to knee – 1 (L,R)
• 0- activity impossible
• 1- severe impairment
• 2- moderate impairment
• 3- mild impairment
• 4- normal impairment

17. Functional assessment (FIM)
• A) SELF CARE:
• FOOD- 5
• CARE OF APPEARANCE- 4
• HYGIENE- 2
• DRESSING UPPER BODY- 3
• DRESSING LOWER BODY- 1
• B) SPINCHTER CONTROL:
• CONTROL OF BLADDER- 4
• CONTROL OF BOWEL MOVEMENT- 4
• C) MOBILITY:
• BED,CHAIR,WHEEL CHAIR- 2
• TO GO TO TOILETS- 1
• BATH TUB,SHOWER- 1

18. • D) LOCOMOTION:
• GO,WHEEL CHAIR- 1
• STAIRCASES- 1
• E) COMMUNICATION:
• AUDITIVE COMPREHENSION- 6
• VERBAL EXPRESSION- 6
• F) SOCIAL ADJUSTMENT/ COOPERATION:
• CAPACITY TO INTERACT AND TO SOCIALLY COMMUNICATE- 6
• RESOLUTION OF THE PROBLEM- 4
• MEMORY- 5
• TOTAL SCORE- 56/126

19. DIAGNOSIS- ACA STROKE ( hemiparesis)
• Problem list-
• Functional disability
• Muscular weakness
• Spasticity
• Reduce ROM
• Unable to sit on her own

20. MANAGEMENT
• SHORT TERM GOALS:
• To make the patient aware about the status of her condition.
• Prevention from secondary complications
• Prevent from deconditioning
• LONG TERM GOALS:
• Maintain all the short term goals.
• Improve strength
• Manage spasticity
• Improve upper extremity function

21. Intervention
• PROM exercises for all joint.
• Icing over spastic muscle for 10-15 mins.
• To improve motor control-
• exercise in lying-
• ankle & toe movement
• hamstring stretching
• TA stretching
• Elbow flexion extension exercise
• Bridging exercise
• Pelvic rotation exercise
• Supine to sit

22. • Exercise in sitting -
• weight shifting exercise while sitting
• To improve muscle strength-
• AROM exercise than gradually progress to progressive resisted
exercises.

23. THANK YOU