Download to read offline
More Related Content
Similar to Stroke assessment
Stroke assessment
- 1. Case presentation Stroke Presented by: Vermasuman (final year)
- 2. Name: Mohanbhai vanjara Age:52 years Gender : Male Address: Gota housing Contact no. : 7436064166 Occupation: Driver Demographic data
- 3. Chief complain: Patient unableto move left upper limb and slightly move lower limb. * difficulty in ADL activities. unable to grip objects, chappal slipping, during walking feel like to going fall, dizziness. Balance problems
- 4. D.O.A: 14/5/2019 D.O.D :17/5/2019 Refferd by : self Hand dominance: left
- 5. Past history: 2years ago, Mohanbhai had awoken in the morning. He not able to move their left hand and leg and loss of sensation. History
- 6. - Then, hewas admitted in shrey hospital on 14/05/2019 with complain of left arm and leg sensation loss & slurred speech. - patient treated with IV Fluids & supportive treatment.
- 7. _ patient wasgradually improved.
- 8. - Now, patient'scondition is better. His all body part sensation is normal. - able to stand & sit. - able to walk with Supporting stick. - able to talk. Present history
- 9. • Mode ofonset : 14/5/2019 • Duration of illness: 2years • Present condition: improved • • Nature of injury: stroke or cardiovascular accident
- 10. Personal past history: Alcohol:everday Vimal :3 to 4 times Bidi :1- 3time Present personal history: Now, patient has stopped taking this(alcohol, vimal) all. Family history: not significant
- 11. Marital history: wife supporting Socioeconomichistory: No. Of family member : 5 - Economic status of his house is good. His both son is earning.
- 12. Psychological history :Anxiety, Depression Educational history: patient is not educated. But his family is educated so easily understand the nature and importance of the treatment.
- 13.
- 14. Present drug history Telmiride40 - for hypertension
- 15. Environmental history Location: Inlane uneven surface Type of home: single family home Stairs: ground floor to 1st floor • No. of steps : 15 • Railing present on right side.
- 16. • 1st flooronly 1room & kitchen. • Two windows in room. • Patient able to close and open the doors &windows. • In bathroom indian toilet.
- 17. Pain history Site :shoulder joint Hip joint Duration: during walking Aggravating factor: in shoulder ( pain start while
- 18. Shoulder range upto 110°). In hip (pain during walking). Relieving factor: rest no activities.
- 19. Body chart forpain location
- 20. Observation Mode of ambulation:dependent Usewalking aids Quaripod stick
- 22. Type of gait •Abnormal • Circumduction gait • Insufficient pelvic rotation during swing phase. • Unstable step • During walking pelvis drop on right side.
- 23. Built: Mesomorphic Type ofrespiration: Abdomino thoracic Pattern of respiration: Symmetrical Deformity : Claw toe, winging of scapula(left side),FFD both knee
- 24. Posture In standing Anteriorview • Left shoulder depressed • Shoulder is adducted • Forearm pronated • Wrist & finger flexed • Hip abducted & externally rot.
- 25. • Externally rotated •Ankle eversion • In posterior view • Shoulder is depressed (left side) • Scapular asymmetrical • Ankle eversion
- 26. In lateral view •Slight forward bending • Round shoulder
- 27. In supine • Rightshoulder elevated • Left shoulder abducted • Elbow flexed • Forearm supinated • Wrist and finger flexed • Hip external rotated • Knee slightly flexed
- 28. Attitude of limb Upperextremity • Shoulder adducted • Elbow flexed • Forearm pronated • Wrist and finger flexed
- 29. Lower extremity • Hipextended and externally rotated • Knee extension • Ankle eversion • Toes flexed
- 30. Palpation Tenderness: Not present Temperature: Normal Tone : stiffness and hypertonic
- 31. Examination • Heart rate:90 •Respiratory rate:18 • Blood pressure:diastolic-124 • Systolic:70 • Temperature: Normal
- 32. Examination of consciousness (Glassgowcoma scale) Best response: 15
- 34. Examination of highermental Function Behaviour: Normal Cognitive function • Patient is alert and oriented to time, place& person.
- 35. • All typeof memory function is normal. • Immediate memory • Recent memory • Remote memory • Verbal memory • Visual memory
- 36. • Intelligence: patient'sability to solve the mathematical problem. • Speech and language: • Apraxia: purposeful movement is not performed by the patient.
- 37. • Perception: Unilateralbody neglect. • Eye contact: maintaining • Dysphagia: difficulty in swallowing. Mini mental state examination (MMSE)
- 38.
- 39. Cranial nerve examination 1stOlfactory nerve Patient can appreciate and identify the odorous. 2nd optic nerve Patient normal visual acuity is affected.
- 40. 3rd, 4th,6th (Occulomotor,trochlear, abducent) • Occularmovements : Normal • Command movements: Normal • Follow movements: Normal
- 41. Examination of pupils: 1) both side pupils sizes is normal 2) shape of pupil is normal 3) pupillary reflexes normal A) Direct light reflex • Pupil dilate
- 42. 5th Trigeminal nerve Testingmotor functions: 1) Temporalis & masseter muscle is normal. 2) Pterygoids: normal 3) Tensor tympani: normal Testing sensory functions
- 43. General sensation:The areaof the face and neck • Fine touch : normal • Crude touch:normal • Temperature:normal • Pain: normal • Pressure: normal
- 44. Test sensation: normal Reflexes 1)Corneal reflex : normal 2) Conjuctival: normal
- 45. 7th Facial nerve Occipitofrontalis,procerus, Orbicularis oculi, Buccinator, Orbicularis oris, Platysma, stapedius this all muscle function is normal. Levator labii superioris alequae nasil: Angle of mouth
- 46. deviated right side. •General sensation: taste sensation anterior 2/3rd of the tongue is normal. • Reflexes: corneal and conjuctival reflexe is normal.
- 47. 8th vestibulocochlear nerve Webertest: positive Rinnel test: positive
- 48. 9th Glossopharengeal nerve Tastesensation normal in posterior 1/3rd of the tongue. Palatal reflex: Normal
- 49. 10th Vagus nerve Softpalate movement is normal. Palatal reflex :Normal
- 50. 11th spinal accessorynerve • Sternocleido mastoid muscle: Normal • Trapezius muscle: Affected left side.. • Drooping of shoulder ( left side)
- 51. 12th cranial nerve •His tongue is normal not wasting, not fasiculation. • Patient able to move their tongue from side to side.
- 52. Assess of motorsystem • Loss of selective movement • Presence of basic limb synergy • In left side Upper limb flexion synergy. • Scapular retraction •
- 53. • Shoulder abduction •External rotation • Elbow flexion • Forearm pronation • Wrist and finger flexion • In left lower limb Extensor synergy • Hip extension & abduction
- 54. • Hip externalrotation • Knee extension • Ankle eversion • Presence of spasticity in left upper limb muscles. • Spasticity in shoulder adductors.
- 55. • Pronator flexors •Elbow flexors • Wrist and finger flexors • Spasticity in left lower limb • Hip adductorsand external rotators. •
- 56. Range of motion MovementAROM Left side PROM Left side Shoulder Flexion 0° 0° to 110° Shoulder extension 0° 110° to 0° Shoulder Abduction 0° to 30° 0° to 110°
- 57. Shoulder Abduction 0° 0° to105° Shoulder External rot.. 0° to 20° 0° to 90° Shoulder Internal rot.. 0° 0° to 60° Elbow Flexion 0° to 150° 0° to 150° Elbow Extension 0° 0° to 150° Forearm pronation 0° 0° to 90°
- 58. Forearm Supination 0° 0° to90° Wrist flexion 0°to 50° 0° to 90° Wrist extension 0° 0° to 70° Ulnar devi. 0° 0° to 25° Radial devi. 0° 0° to 20° Finger flexion 0° to 30° 0° to 90°
- 59. Hip flexion 0°to 40° 0° to 70° Hip extension 40° to 0° 70° to 0° Hip abduction 0° to 35° 0° to 55° Hip adduction 35° to 0° 55° to 0° Hip internal rot.. 0° 0° to 5° Hip external rot.. 0 ° to 20° 0° to 90=
- 60. Knee flexion 0° to 120°0°to 140° Knee extension 120° to 0° 140°to 0° Ankle planter flexion 0° to 20° 0° to 35° Ankle dorsi Flexion 0° 0°to 20°
- 61. MMT • Mmt isnot taken in this patient because of involuntary movement occur while performing purposeful movement.
- 62. Reflexes a)Deep tendon reflex Grade 1) jawjerk ( C5) Normal 2) biceps (C5, C6) 3+ brisk 3) brachioradialisC5C6 3+ brisk 4) Triceps (C6, C7) 3+ brisk 5) knee jerk L3,L4,L5 3+ brisk 6) Ankle jerk( S1,S2) Normal
- 63. b) superficial reflex Grade 1)Cornial reflex Normal 2) Conjuctival reflex Normal 3) Abdominal reflex Normal 4)Babinski sign Positive
- 64. Pathological reflexes 1) Chaddockssign : +ve
- 65.
- 66. 3) Hoffman reflex: -ve
- 67. 4) Rossolimo reflex: +ve
- 68.
- 69. Muscle tightness Right sideLeft side Calf muscle Biceps Hamstring Forearm flexor Calf muscle Hamstring Hip adductors
- 70. Sensory examination 1)superficial sensation Right Side Left Side a) painNormal Normal b) Touch Normal Abnormal c) Temperature Normal Normal
- 71. 2) Deep Sensation Right Side Left Side Proprioception NormalNormal Vibration Normal Affected Kinesthesia Normal Normal
- 72. 3) cortical Sensation Right sideLeft side a) Tactile localization Normal Affected b) Two point discrimination Normal Affected Stereognosis Normal Normal graphesthesia Normal Affected e) Barognosis Normal Normal
- 73. Dermatomes • Sensory impairmentat the palmer and dorsal aspect of the left hand. • C5,C6,C7 and T1 dermatomes is affected. • C1 to C4, T2 to T12, L1 to L5 & S1 toS4 dermatomes normal.
- 74. Vibration • The patientnot sensed the vibration on the bony malleolus of the ankle.
- 75. Muscle Girth Muscle Rightside Left side 1) Biceps 27cm 27cm 2) Deltoid 30cm 30cm 3) Forearm Mucle 25cm 25cm 4)Quadriceps 40cm 40cm 5) Gastrox 34cm 34cm
- 76. LLD Pelvic squaring Umbilicus toASIS Rt-37cm Lt-37cm Both ASIS in same level. • Apparent LLD
- 77. Umbilicus to medialmalleolus Rt- 99 cm Lt- 99cm True LLD ASIS to medial malleolus Rt- 96cm Lt- 96cm
- 78. Co- ordination &balance Equilibrium test 1) standing feet together 2)standing one foot in Front of other 3)walking on a straight line 4)walking sideways 3 4 2 2 Grade
- 79. 5) Stand onone leg 6) Marching 3 2
- 80. Non Eqllibrium test 1)Finger to nose 2) Finger to therapist's finger 3) Finger to finger 4) Finger opposition 5) Mass grasp Grade 0 0 0 0 0 0
- 81. 7) Rebound test 8)Tapping (hand) 9) Tapping (foot) 10)pointing & pastpointing 11) alternate heel to knee, knee to heel 12) Toe to examiners finger 13) Heel on shin 2 0 4 0 3 4 2
- 82. 14) Drawing circle 15)Fixation or position holding 1 2
- 84.
- 87. • Time upand go test: patient takes >>12 second to complete the TUG is at risk for falling. • patient takes 26sec to complete TUG. • Functional reach test: starting point : 77cm to final point :87cm.
- 88. Multi direction reachtest. • Patient this test perfomed by right hand because left hand is affected and he unable to raise left hand.
- 89. Multi direction reachtest • Forward reach test: starting point 77cm to end point 89cm. • Backward reach test: starting point 77cm to 74cm. • Lateral reach to right : starting point 77cm to 85cm.
- 90. 1) Time upand go test:
- 91. 2) Functional reachtest:
- 94. • In bergbalance scale: patient's total score 35 out of 56. • The score is 35 that indicates medium risk of falling.
- 95. Bowel and bladder examination Boweland bladder function is normal.
- 96. Gait examination • Modeof ambulation:Dependent • Use walking aid : quadripod stick • Measurement of quaripod stick
- 97. Wrist to floor:83cm
- 98. Type of gait:Circumdunction gait Or hemiplegic gait
- 99. • Step length: 63cm • Stride length: 63cm • Width length: 30cm • Toe out angle: 22cm • Cadence: 45 steps per 1 minute
- 101. • Insufficient Pelvicrotation during swing phase. • During swing phase pelvis drop on right side. • Heel strike phase absent on left side(affected side). • Abnormal and large step length.
- 102. Exercise tolerance test 6minute walk test: 6MWT Before heart rate: 88/1min • 6MWT after HR:105/1min • Patient 6MWT is completed with external aids supportive stick is used. • Patient covered a distance
- 103. of 30 meters. •During walking take rest time for 1 minute. • 6MWT after taken borg scale score : 7
- 105. ADL assessment FIM scale:score 99/126 Barthel index scale: score 60/100 Katz index of independence Of activities in daily living: Score 3/6
- 106.
- 107.
- 110. Trunk impairment scale: TISscore 11out of 23.
- 111.
- 112.
- 113. For Stroke assessmentscale 1) Glassgow coma scale 2) mini mental state examination scale 3) berg balance scale 4) FIM scale 5) Barthel index scale
- 114. 6) katz indexof Independence in daily living life. 7) Trunk impairment scale 8) Forward reach test 9) Time up and go test 10) 6 minute walk test 11) borg scale
- 115. 12) upper extremity functionalindex scale 13) lower extremity functional scale
- 116. Investigation • MRI ofbrain • Angiography
- 121. Diagnosis: Left hemiplegia Provisionaldiagnosis: Right stroke& hypertension
- 122. ICIDH2 Scale Part 1:Functioning and Disability a) Body functions and structures - body level b)Activities (individuals levellevel) and participation
- 123. Part 2:Contexual Factors a)Environmental Factors b) personal Factors
- 124. Body structures (Anatomical) Normal •Brain, arteries of brain • Joint, organs, muscles Abnormal Structure affected Hemiplegic patient •Anterior cerebellar artery • Muscle • Artery and veins • Heart Primary secondary
- 125. Body functions (physiological) Normal Relatedto brain and artery all functions Secondary structures such range of motion, pain etc Abnormal functions Primary • Aletered sensation Secondary • Loss of range of motion
- 126. Body functions (physiological) Abnormal Functions •Visual neglect • Pain(hip, shoulder) • Muscle weakness of upper &lower limb. • Hypertonic • Hyperflexia • Difficulty in • Loss of muscle legth tightness. • Loss of movement or mobility.
- 127. Abnormal Functions • Swallowing • Abnormal synergy •Alteref motor functions • Altered perception • Poor emotional status • Edema in hand • Impaired postural control & balance. Body functions (physiological)
- 128. • Activities (individual level) 1) Learning & applying knowledge : memory for daily living activities is normal. 2) self care : brushing, dressing, grooming, feeding or eating, toileting activity due to lack of function , this activity is affected.
- 129. 3) Communication: withguests, family member is normal. 4) Mobility: Difficulties in transfer activities from one room to another, from sofa to floor, getting in bed & out of bed, stair climbing .
- 130. Sitting, standing prolong,laying supine snd prone due to weakness of limbs & trunk. 5) Domestic life: patient able to opening & closing doors, transfer object to self or bring it down, pulling & pushing objects.
- 131. 7) Interpersonal relationship: communication,helping etc will be normal. Participation restriction • • Social gathering- marriage, party, shopping • Participation in work
- 132. • Vehicle driving,sports • Participation for job, visiting multiplex or mall, gardens, temple. • These all participations will be restricted.
- 133. Part 2 Contextualfactors: Environmental factors: Home • Facilitator Railing, height of sofa, distance of house to clinic 2km Barriers Stair, 2nd floor pts lives, indian toilet Social fctors Earning of family, pt's life (married) No any barrior
- 134. Social factors Facilitators • Socioecono- mic statusis good • behavior of members helpful. • Help in exercise at home. • Help in selfcare • Relationship is good. Barriers No any barriot
- 135. B) personal factors: Domain Facilitators •Condition improved • Patient cooperation is good Barriers Hypertension • Deal with stress & depression • Job loss • Education lower • domain hand affect
- 136. Problem list 1) gaitabnormalities 2) Imbalance 3) Impaired motor function - Tonal abnormalities - Muscle weakness - Synergistic pattern - Tightness
- 137. 4) Increase stiffnessof muscles. 5) Difficulty with swallowing. 6) Postural abnormalities 7) Functional disability 8) Incordination