Lets take a look at this case study from a typical stroke presentation 👇
Presenting Complain: Inability to use the Left upperlimbs and lowerlimbs Secondary to a Left Hemispheric CVA with associated slurred speech and facial deviation.
Now pay attention
History of presenting complain: Now he was apparently healthy and well until about 5 days ago when He got up to urinate around midnight and noticed He couldn't lift his right hand and leg when He tried getting off the bed. Now there was no loss of consciousness, convulsion or vomiting during the event.
There is no preceeding history of stroke in the family. He was subsequently taken to the hospital and admitted in accident and emergency Unit.
He has being referred for Physiotherapy on account of the above stated presentations.
Past medical history
He is not a sickle cell patient and has no blood disease or infection
He was diagnosed of hypertension about 2 years ago, he was not drug compliant, neither was he clinic compliant.
He is not athmatic and had no known cardiopulmonary conditions
He is not diabetic, recent blood sugar level reads 4.2mmol/L
He is not epileptics, and definitely has no proceeding history of convulsion, seizure or abnormal brain activity.
He has no known history of peptic ulcer disease and inflammatory bowel disease.
He has no preceding History of admission on account of stroke or any other medical conditions
Drug History : Tab Rosvastatin, IV Amlodipine, Vit C, Vasoprin
Surgrocal History: None (He never had any form of surgery done)
Family and Social History: He is a 77 year old civil servant . He is married in a monogamous setting and has 3 Children. He lives in a duplex with his wofe and children. He smokes and drinks alcohol regularly.
Communication
Cognition
-Limited attention span
-He exhibited Delayed response to questions and motor commands
Language
-Patient has difficulty expressing himself clearly( Expressive Aphasia).
We have the expressive aphasia which is due to an affectation of the broddmans area .
We also have the receptive aphasia which is due to an affectation to Wernicke's area .
Now he understands, but has trouble expressing and relaying information.
Observation and Examination: He was met in supine-lying with an IV-line tube attached on the Lt dorsum of the hand. Pt is conscious and not in any obvious respiratory distress.
Vitals
BP- 135/78mmHg (notice that his blood pressure here was almost normal due the fact that he has been placed on antihypertensive - amlodipine )
PR- 85bpm
RR- 21cpm
SPO2- 96%
GCS- 14/15
Eye opening - 4
Best Verbal Response - 5
Best Motor Response - 5
Segmental Examination
Head and Neck
- The angle of the mouth is deviated to the left
- Weak eye closure of the right eye
Thorax and Abdomen
- No abnormality detected
Right upperlimb
-- Muscle bulk is preserved
-- Muscle Tone - Flaccidity
-- Sensation- Impaired
-- Pain - Mild (VRS- 3/10 )
-- GMP - 0, no contraction
-- PROM - Full and Painfree
-- Swelling - Absent
Left Upperlimb
Gross Muscle power - 4/5
Right Lowerlimb
Muscle bulk is preserved
Gross Muscle power of 1/5 this actually means that there was contraction but no movement
Sensation is impaired
Passive range of motion is full and painfree
Edema and swelling is absent (mean venous return is most likely not compromised , neither is there any form of inflammation to warrant swelling)
Tendon Achilles Tightness is absent
Left Lowerlimb
GMP- 4/5 ( This means he was able to move the left lower limb against a resistance)
Radiological Findings
There is an extensive area of hypodensity seen involving the left parietemporal regions and occipital regions with surronding perilesional edema. There is associated mass effect as evidenced by narrowing of the ipsilateral lateral ventricles.
Radiological Impression is extensive acute left cerebral Ischaemia in the vascular territories of the Mid cerebral artery, Anterior Crrebral Artery and posterior Cerebral Artery.
Now from the report of the radiograph there would be a need to assess him as regards his memory just to make sure no stone is left unturned . And dont forget that he has trouble expressing himself
Remember that the parietal lobe is responsible for short term memory which enable things like solving mathematical problems , while the temporal lobe is responsible for long term memory.
To assess long term, he can be asked the name of his wife and children even things like the organisation where he works .
Clinical Impression
Right Hemiplegia Secondary to Left Hemispheric CVA.
Functional Status
-Pt cannot turn in bed
-Pt cannot sit in bed
-Pt cannot stand
-Pt is maximally dependent in ADLs
Analysis of Findings
-Weakness of the Right Upperlimbs and lowerlimbs muscles
-Sensation is impaired on the Rt side of the body.
-There is mild facial paresis of the Rt side of the face. This is definitely an Upper Motor Neuron lesion form of facial palsy, how? Just check if he can wrinkle the forehead, which in this case he can if he can wrinkle is forehead it a confirmatory diagnosis that the presentation is UPPER MOTOR NEURON related
-Pt is not ambulant and dependent on caregiver in activity of daily living.
Plan
- To strengthen the weak muscles of the Right Upperlimb and Lowerlimb
- To improve sensation and awareness of the Rt side of the body
- To improve patient mobility in bed
- To correct facial paresis and inprove facial symmetry
- standing and walking reeducation
- Gait-retraining and gait reeducation
- Patient and Caregiver education
Interventions
-Passive Mobilization to the Rightt Upperlimbe and Lowerlimbs
-Therapeutic Positioning, there is something we call proper positioning of stroke patients, this help to prevent other musculoskeletal complications
- Tactile stimulation this will certainly help to preserve muscle integrity and restore sensorial activities
- Auto-assisted exs to the ULs and LLs
- Bridging exercises
- Weight bearings on affected limbs.
- Rolling from side to side.
- Facial exercises
- Free active Exercises to the bilateral upperlimbs and lower limbs
- Sitting re-education in bed
- Standing re-education
- kineosotaping to correct facial paresis
Now the above is a physiotherapy based rehabilitation approach to left hemispheric ischaemic CVD, involving assessment, examination, analysis of finding, planning then intervention.
Thanks you so much for reading this far, I hope you have been able to gain one or two things.
THANKS FOR READING SAYONARA 🖐️
References
https://www.physio-pedia.com/Stroke?veaction=edit
https://www.physio-pedia.com/Stroke:_The_Role_of_Physical_Activity
https://www.physio-pedia.com/Category:Stroke
https://www.physio-pedia.com/Category:Stroke_-_Conditions
https://www.msdmanuals.com/en-nz/professional/neurologic-disorders/stroke/overview-of-stroke
Physiotherapy is a very important aspect of stroke management. The treatment of stroke cannot be complete without Physiotherapy as well as speech therapy, occupational therapy etc.
Thanks so much for sharing.
Absolutely, for the case of aphasia, especially the expressive one, a speech therapist is needed, for the fine tuning of motor movement, an occupational therapist comes on board. Its a multidisciplinary approach to enable optimum outcome for the patient
Very correct
I am a bit unclear if this is a real case or a fictional one (^^')
Oh! it is actually a case study analysis, involving my plans and interventions from a real case which I managed as a physiotherapist.
Its a typical left hemiplegic case of stroke caused by CVD.
Thanks for your contribution to the STEMsocial community. Feel free to join us on discord to get to know the rest of us!
Please consider delegating to the @stemsocial account (85% of the curation rewards are returned).
You may also include @stemsocial as a beneficiary of the rewards of this post to get a stronger support.