Re evaluation

Px Name : Carrasco, Florentina

Age : 69 years old
Sex : Female
Diagnosis : Acute CVD infarct
Subjective:
C/C Medyo mahina yung kaliwang parte ng katawan ko at masakit yung
kaliwang balikat ko c ps of 6/10
PT Translation : Px complaints of weakness on (L) part of her body and dull
aching pain on (L) shoulder c ps of 6/10.
Objective:
VS : Before 130/90mmHg

After 130/90mmHg

OI :
Wheelchair bound
Ectomorph
A/C/C
(+) Shoulder sublaxation on (L)
(+) Edema on (L) foot
(-) Typical arm posture
(-)Scanning speech
(-)Deformity
(-)Dry skin
Palpation:
Normothermic on all exposed body parts
Hypotonic on B (L) UE and LE except elbow flexors (biceps brachii)
(+) muscle weakness on (L) UE/LE c grade 2
(+) grade 2 tenderness on (L) shoulder
(-)muscle spasm
(-)muscle guarding

DTR

Legend : 0 = areflexia
+=hypereflexia
++=normoreflexia
+++=hyperreflexia
++++=clonus

Findings: Hyperreflecia on B (L) UE

Significance : 2 UMNL

Pathologic reflex :
(+) Babinski reflex
Px withdraws her foot after the maneuver.
ROM:
All major muscles are WNL actively and passively done pain free except for :
MOTION

ACTIVE

PASSIVE

(N)

ENDFE
EL
DIFFERENCE

(L)
flexion

Shoulder

0-50

0-180

0-180

(L)
Shoulder
abduction
(L)
Elbow
extension
(L) Wrist ulnar
deviation
(L) Wrist radial
deviation

0-50

0-180

0-180

0-135

0-135

0-135

0-10

0-30

0-30

0-15

0-20

0-20

(A)
0-130
0
0-130
0
0
0
0-20
0
0-5
0

(P)
FIRM
FIRM
SOFT
FIRM
HARD

(L) Hip flexion

0-125

0-120

0-120

(L) Knee flexion

0-90

0-150

0-150

(L)
Ankle
Dorsiflexion
(L) Ankle plantar
flexion

0-10

0-20

0-20

0-5

0-50

0-50

0-5
0
0-50
0
0-10
0
0-45
0

FIRM
SOFT
FIRM
FIRM

Findings : Px cant able to complete full ROM

Significance : Due to muscle weakness and pain.
MMT
All major muscle are grossly graded 5/5 except for
(L) Shoulder flexion
2/5
(L) Shoulder abduction
2/5
(L) Elbow extension
2/5
(L) Wrist ulnar deviation
2/5
(L) Wrist radial deviation
2/5
(L) Hip flexion
2/5
(L) Knee flexion
2/5
(L) Ankle Dorsiflexion
2/5
(L) Ankle plantar flexion
2/5
Findings : Px cant able to achieve optimal muscle strength on (L) UE and LE
Significance : D/t muscle weakness
Neuro Evaluation:
Brush for light touch, pin for pain and thumb for deep pressure
Findings : 100%Intact sensory on UE/LE ; 50% intact sensory on (L) UE/LE
Significance: 2 UMNL
Cranial Nerve Testing:
All Cranial nerves are intact except for cranial nerve VII
Cerebellar Evaluation:
Px has intact Proprioception and Kinesthesia on (B) UE\LE
MBM
Reference top of Patella (R 5Above is 12) (L 5Above is 13)
LGM
Reference medial malleolus (R=20) (L=21)

Functional assessment :
Px can assume and maintain sitting/ standing balance and tolerance.
D/t muscle weakness
ADL
Self care
Eating
Grooming
Bathing
Dressing UE
Dressing LE
Toileting
Sphincter Control
Bladder management
Bowel management
Mobility (Transfer)
Bed, chair, W/C
Toilet
Tub, shower
Locomotion
Walk
Wc
Stairs
Communication
Comprehension
Social Cognition
Social interaction
Problem Solving
Memory

7
3
3
3
3
2
2
2
2
2
2
2
2
2
1
7
7
7
7

Findings : Px has difficulty in all aspects of ADLS as to self care, sphincter

control, Mobility and locomotion.
Significance : Due to muscle weakness ; decrease in sitting balance and
tolerance; and pain
Assessment:
PT impression: Px was medically diagnosed to have Acute CVD infarct which
complaints of muscle weakness and difficulty in all aspect of ADLS.
Rehab Prognosis : Px has good rehab potential because shes very
cooperative and willing to do all given PT management.
Problem list
1. Maximal dependence on ADL

2. Pain on (L) shoulder c ps of 6/10

3. LOM on B UE and LE
4. Weakness in all (L) muscles group such as sh flexion, shoulder abd,
elbow flexion, wrist ulnar devt, wrist radial devt, hip flexion, knee
flexion, ankle DF, and ankle PF c ms grade of 2/5
5. Edema on (L) LE
STG (6-12 Tx sessions)
1. To achieve from maximal dependence to moderately dependence on
ADL
2. To decrease pain of (L) shoulder from 6/10 t0 4/10
3. To increase ROM on B (L) UE and LE by 5 increments
4. To increase muscle strength on (L) muscle group from grade 2 to 3.
5. To improve sitting and standing tolerance
LTG
1.
2.
3.
4.

To
To
To
To

achieve near normal in all aspect of ADL

eliminate pain on (L) shoulder
achieve near normal ROM
achieve near normal muscle strength

PT Mx :
1. ES on B Flexors and extensors on B (L) UE and LE X 20
2. TENS on (L) knee X 20
3. AAROMES on B (L) UE/LE X 10 reps X 1 set
4. AAROMES on B UE and LE with 2 lbs DB X 10 reps X 1 set
5. PRES on (B) R UE and LE X 10 SH X 10 reps X 1 set
6. Core strengthening X 7SH X 10 reps X 1 set
7. Standing balance exercise X 5
8. Ankle Pumping for 5

Christine B. Balasbas
UPHS-GMA PT INTERN
2016