[Solved]: Mr

Mr. Patel is a 59-year-old who experienced an intracerebralhemorrhagic stroke affecting the Left internal capsule and putamen (diagnosed by CT followed up with MRI). He was transported to the ED by his daughter with complaints of severe headache x 1 hour and sudden loss of speech, facial droop, and hemiplegia. He was stabilized in the ED with medications to reduce blood pressure, and within 48 hours underwent surgery(endoscopic evacuation) to evacuate a moderate sized hematoma. Post-surgical complications included a mild left sided pneumonia (diagnosed with chest x-ray) that prolonged time two weeks in the neuro ICU. Patient now transferred to the acute care stroke unit to begin therapy and become more stable before being able to go to acute inpatient rehab.Mr. Patel lives with his wife, his 24-year-old daughter and his 82-year-old mother. Mr. Patel works in sales for a large corporation that manufactures computers and other electronic equipment. He enjoys golf on weekends, but his job involves a good deal of travel, and he reports being fairly sedentary during the week. His wife works full time as a bank executive and his daughter is in graduate school full time. Part 2Systems reviewCardiovascular:Vitals: 137/88, 90 bpm, 18 rpm; O2 sat of 96; (vitals consistent across last several days)Was initially on supplementary O2 due to desaturation, but has not required O2 for past 12 hoursPMHs of hyperlipidemia and hypertension (was on Crestor and Lisinopril pre-morbid, continues on these); has history of exercise induced asthma and uses an albuterol inhaler to managePost stroke pneumonia, managed with antibiotics and respiratory therapy (nebulizers and supplemental 02)Integumentary: Skin is intact. Mild edema noted in R hand and R foot/ankle; non-pittingNeuromuscular:R UE appears flaccid; R LE appears weak but has proximal activationMusculoskeletal: No AROM in R UE, but PROM appears WFLAROM/PROM in L UE is WNL1 finger inferior shoulder subluxation noted on RPROM in bilateral LEs reveals mild tightness in bilateral hip flexors, hamstrings, and R gastroc (see below). AROM normal on R LE is limited (see below); AROM on L LE is normalNo skeletal deformity is noted, but his resting sitting posture assessment demonstrates rounded shoulders, forward head, excessive posterior pelvic tilt along with R scapular abduction and downward rotation and increased weight bearing left hip.Cognition/Communication: Mr. Patel has significant muscle weakness in the face resulting in dysphagia and dysarthria. However, he is able to follow multi-step commands, and is accurately able to answer yes/no questions using head nods (and occasional accurate verbalization). He appears oriented x 4 with questions modified to yes/no answers and when given a choice of 2 answers. He appears frustrated at times with his inability to communicate normally. Additional Examination findingsBalance: Supervision with static and dynamic sittingModified Functional Reach test of 6 inches (reaching with L UE)Requires Mod Assist to stand statically, and Max Assist for dynamic standing (reaching tasks with L UE) Assist is being provided at the knee to prevent buckling and hip extensors to maintain hip extension and trunk for upright.Muscle tone: Normal L UE and LE; R UE is flaccid, R LE is hypotonic below the knee, Hip extension strong contraction noted with glut sets, and quads 2/5 able to extend knee partial range against gravity but unable to sustain PROM: Bilateral SLR 50 degrees, Thomas test bilaterally lacking 10degrees iliopsoas , 0 degrees DF on R with knee flexed and lacking 5 degrees of DF with knee extended.Sensation: Impaired light touch and sharp dull on R UE and LE; Normal kinesthesia for large range motion, impaired for small ranges R UE and LE; all normal on L Function: Currently Mod Assist for Sit pivot transfers (w/c to mat, bed) to shift weight forward and activate right LE and weight bear onto that legSit<>stand with Max Assist to facilitate pre-extension phase, increased weightbearing on right lower extremity and assist to facilitate hip extension and prevent buckling in extension phaseOverall Mod Assist in bed mobilityRolling with Supervision to R, Mod Assist to LMax Assist with supine<>sit and scootingWheelchair propulsion: Modified Independence for 150 over level surfaces, propelling with L UE and LE.Ambulation has not yet been attemptedAny additional info needed to create goals and POCPatient Goals: Mr. Patel is unable to state his goals for therapy. He gestures to indicate that he wants to get up and walk. His wife expresses goals of being able to get around the home independently and be as independent as possible. Psychosocial: lives in 2 story home, and his bedroom is on 2nd floor. Downstairs is accessible as they had modifications made for his mother when she came to live with them. The home has a one step entry but there is a handrail on the right side. It is possible that Mr. Patel could live downstairs initially if needed. His wife works full time and will need to take off time for work if he requires assistance during the day when he discharges home. His daughter expressed a willingness to take time off graduate school to help with her fathers care. Mr. Patel became very upset when he heard this and emphatically shook his head no. Part 3Mr. Patel has been discharged now to an inpatient rehab facility for comprehensive rehab. The tentative discharge plan from here is to d/c home with family, but family is still discussing who will provide care during the day if he needs continual care. Mr. Patel is considering early retirement if he does not progress back to being able to return to work. If he does this, it is important that his wife continue to work. His goals for inpatient rehab are to be able to walk and take care of himself so that he can be home alone (with elderly mother who cant provide care) and to be able to use his hand and speak his basic needs clearly.Systems reviewCardiovascular:Vitals: stable; no issues; continues on anti-hypertensive (Lisinopril) with adjustments in dose. BP is now in range from 124/78 to 140/90. Integumentary: No skin breakdown. Still mild edema in R handNeuromuscular: Improved activation and strength throughout; some mild tightness and hypertonicity (see below):L UE and LE: normalR UE: has 1-2s in shoulder flexor, abd, add; 2 in elbow flex; 0-1 in elbow extensors; 0s in wrist and finger flex/ext, forearm sup/proR LE: 2 hip flex/abd; 1 hip ext; 3 knee ext; 1 knee flex; 1DF; 0 PF R MAS: 2 in PFs, 1 in quads, 3-5 beats clonus in PF; R UE still appears hypotonic but rests in elbow flexion and internally rotated position. Musculoskeletal: Thomas test on L lacking 5 degrees iliopsoas and stiffness noted in rectus femoris knee flexion70 degrees, mild stiffness in hamstrings bilaterally; L ankle 0 degrees DF with knee flexed and lacking 5 degrees of DF with knee extended Sensation: not changedLanguage/communication: Continues to suffer from dysarthria, but has been working hard in speech therapy. At times, it is difficult to decipher his words and Mr. Patel does get frustrated easily with this. He is able to get his point across clearly about 50% of the time. At this point, Mr. Patel continues to be on a nectar thick diet with a swallow study scheduled in a few days to determine if he is able to advance his diet. Additional Examination findingsBalance: Mod I for static and dynamic sitting balance; Modified Functional Reach test of 8 inchesSupervision to occasional Min Assist for static standing, but tends to overuse L UE and LE; stands asymmetricallywith midline over left side. Min to Mod Assist for more for dynamic standing; unable to complete Functional Reach in standing because requires assistPASS: 16/36 with difficulty with more dynamic items and standing items. Unable to perform items 3,4,5,12 and requires some type of assist for postural adjustments.Function: Min assist squat pivot transfers either direction even surface to facilitate forward weight shift and needs verbal cues to use right LE.Mod Assist to facilitate hip extension and keep knee from buckling during stand pivot with large base quad cane Rolling toward L with Min, Rolling toward R with Mod IR sidelying to sit with Mod AssistL sidelying to sit with SupervisionBridging with Min Assist to stabilize legsScooting with Min to Mod Assistw/c mobility: over level surfaces > 1000 using L UE and LE.Ambulation: ambulating up to 50 with RW with Rhand secured to handle , with Max assist at R LE for stance stability and swing limb clearance. Tends to buckle at knee or maintains knee locked out into full extension when weightbearing during stance. Lacks hip, knee flexion and ankle DF during swing, so unable to clear limb without assist.