• GENERAL INFORMATION

• Pt NAME: Jun Flores

• AGE: 45 YEARS OLD
• GENDER: MALE
• ADDRESS: 187 BASECO, TONDO, MANILA
• CIVIL STATUS: MARRIED
• CONTACT NUMBER: 412-2869
• HANDNEDNESS: LEFT HANDEDNESS
• OCCUPATION: CASHIER TELLER
• RELIGION: CATHOLIC
• REFERRING DOCTOR: DR. TAN
• REFERRING HOSPITAL: PHIL. GENERAL HOSPITAL
• REHAB DOCTOR: DR. GO
• REHAB UNIT: PLM-CBR
• DATE OF INITIAL EVAL: FEB. 14, 2009
• DX: ® MCA THROMBUS
• I/R: MAY FLORES(WIFE)/FAIR
HPI:

PRESENT CONDITION STARTED 2 MONTHS

PRIOR TO INITIAL EVALUATION, WHEN PT FELL
OUT OF BED. HIS WIFE NOTED (L) SIDED
WEAKNESS, SLURRED SPEECH, AND
ABNORMAL POSTURE WITH HIS HEAD TURNED
TO THE RIGHT. HIS MEDICAL ILLNESS IN THE
PAST WAS A LEFT SUPERFICIAL FEMORAL VEIN
DVT THAT HE SUSTAINED FOUR YEARS
PREVIOUSLY DUE TO HIS JOB AS A CASHIER
TELLER. BLOOD PRESSURE IS ELEVATED TO
140/100. PX IS TAKING ASPILET AND
CHOLESTAD FOR MEDICATION. 2 WEEKS
PRIOR TO INITIAL EVALUATION, PT CONSULTED
REHAB MD AND WAS REFERRED TO PT FOR
FURTHER REHABILITATION.
 ANCILLARY
PROCEDURES
PROCEDURE FINDINGS
XRAY AP RADIOGRAPH
SHOWED NO
BONE FX
MRI (+) OCCLUSION
OF ® MCA
CT SCAN UNREMARKABLE
DX
DRUG
Hx
DRUG INDICATIO DOSAGE FREQUEN
N CY
Aspilet Anti- 160 mg OD (for 30
coagulant days)
Cholestad Hyperlipi- 10-20 mg OD
demia (evening)
PMHx
(+) HTN
(+) DM
(--) Hospitalization
(+) DVT
(--) Surgical operation
FMHx
Mother Father
HTN -- +
DM + --
Heart + --
disease
 PSEHx
• Occasional alcoholic beverage drinker (2-3
bottles/occasion)
• Smoker, 14 sticks/day
• Educational attainment: High school graduate
• Cashier for 5 yrs prior to injury
• Pt works 8 hrs/day, 5 days/wk
• Poor financial support, he is presently supported by
his older sister but is still insufficient
• Lives in a bungalow with his wife and son
• Pt commutes by riding a jeep and tricycle when
going to work
S:

 C/C: Spasticity of (L) UE c difficulty in

ADL
 PT’s goal: To be able to restore to his
maximal potential
O:
VS:

BP 140/100
PR 80 bpm
RR 18 cpm
OI:
 Endomorph
 Modified independent ambulation using
 (+) gait deviation (see gait analysis)
 (+) postural deviation (see postural analysis)
 (--) attachments
 (--) trophic skin changes on (B) UE and LE
 (--) wound and scar on (B) UE and LE
Palpation
Normothermic on all
exposed body parts
(+) synergy on (L) UE
ROM: All jts of ® UE & LE
are WNL
All jts of (L) UE & LE are
limited ACTIVE ROM PASSIVE ROM
MOTION
GH flexion 0-100 0-120
GH extension 0-20 0-30
GH internal 0-50 0-60
rotation
GH external 0-40 0-50
rotation
GH abd 0-70 0-80
GH add 0-50 0-90
Elbow flexion 0-70 0-80
Elbow extension 0-5 0-50
Forearm 0-30 0-40
MOTION ACTIVE ROM PASSIVE ROM
Wrist flexion 0-40 0-60
Wrist extension 0-50 0-30
Ulnar deviation 0-20 0-30
Radial deviation 0-10 0-20
MCP flexion 0-40 0-50
MCP extension 0-5 0-15
MCP abd 0-5 0-10
MCP add 0 0
PIP flexion 0-70 0-80
PIP extension 0 0
DIP flexion 0-70 0-90
DIP extension 0-10 0-20
Thumb flexion 0-40 0-50
Thumb extension 0-30 0-40
Thumb abd 0-20 0-30
Thumb add 0-20 0-35
All jts of (L) LE are weak
except Hip adduction & ankle
Plantar Flexion
Motion AROM PROM
Hip Flexion 0-100 0-120
Hip Extension 0-10 0-20
Hip Abduction 0-30 0-40
Hip Adduction 0-30 0-30
Hip Lateral Rotation 0-30 0-40
Hip Medial Rotation 0-20 0-30
Knee Flexion 0-100 0-120
Knee Extension 0-10 0-10
Knee Medial Rotation 0-15 0-25
Knee Lateral Rotation 0-20 0-30
Ankle Plantarflexion 0-35 0-35
Ankle Dorsiflexion 0-10 0-40
Ankle Supination 0-30 0-40
Motion AROM PROM
Ankle Pronation 0-10 0-20
Toe Flexion MT 0-30 0-35
PIP Flexion 0-25 0-35
DIP Flexion 0-45 0-55
Great Toe MTP 0-30 0-40
Flexion
IP Flexion 0-30 0-40
Toe Extension MTP 0-30 0-40

PIP Extension 0 0
DIP Extension 0-20 0-30
Great Toe MTP 0-60 0-80
Extension
IP Extension 0 0
Neuroevaluation
SENSORY TEST
Superficial Sensation
STD’s: Pinprick for pain
Brush for Light Touch
Blunt edge of neurohammer for
Pressure
Findings: Severe Loss of sensation on (L) UE &
(L) face
Significance: Sensory loss 2˚ to affectation of
Brodmann’s (Area 312)
Functional Significance: Modality Precaution
Deep Sensation
Proprioception: All jts. are intact except on (L)
UE
Findings: Unable to identify position of (L) UE
Functional Significance: Self care and work-
related considerations
Kinesthesia: All jts. are intact except on (L) UE
Findings: Unable to identify the direction of
movement of (L) UE
Functional Significance: self-care and work-
related considerations
Combined
Stereognosis Perception
Findings: Pt. cannot identify variety of small
easily obtainable and culturally familiar
objects like keys coins and balls on (L)
UE.
Double Simultaneous Stimulation
Findings: Pt cannot perceive touch stimulus
and number of stimuli on (L) UE
Tone Assessment
®UE - Normotonic
(L) LE-Normotonic
(L) UE-Hypertonic
® LE- Normotonic
Findings: Hypertonic on (L) UE
Functional Significance: self-care and
work-related considerations
Memory
Short Term Memory Assessment: Sequence
should be repeated by the patient.
Findings: pt unable to repeat the number after
5 min.
Significance : Pt is unable to repeat the
numbers due to ideational apraxia
Visual Acuity
Assessment: Peripheral eye field vision test
Findings: (+) on (L) homonymous hemianopsia
Significance: (L) homonymous hemianopsia d/t
affectation of optic radiation in the internal capsule
DTR:

 BICEPS TENDON -- HYPERREFLEXIVE

 TRICEPS TENDON -- HYPERREFLEXIVE
 HAMSTRING TENDON-- NORMOREFLEXIVE
 ACHILLES TENDON -- NORMOREFLEXIVE
 PATELLAR TENDON --NORMOREFLEXIVE
POSTURAL ANALYSIS
ALL BONY LANDMARKS OF (B) LE/UE ARE LEVELED EXCEPT
FOR:
ANTERIOR VIEW:
• HIGHER (L) SHOULDER
• HIGHER (L) CLAVICLE
• HEAD TURNED TO THE (R)
LATERAL VIEW:
• SLIGHT INCREASED THORACIC KYPHOSIS
• DECREASED LUMBAR LORDOSIS
POSTERIOR VIEW:
• HIGHER (L) SHOULDER
• HIGHER (L) SCAPULAR SPINE
• HIGHER(L) INFERIOR ANGLE OF SCAPULA
FINDINGS: (+) POSTURAL DEVIATIONS
SIGNIFICANCE: THE HIGHER (L) SHOULDER AND CLAVICLE IS
PROBABLY d/t SPASTICTY OF MM.
GAIT ANALYSIS:
 CIRCUMDUCTION OF (L) LEG DURING
SWING PHASE
 THE (L) UPPER LIMB IS CARRIED
ACROSS THE TRUNK FOR BALANCE

ANTHROPOMETRIC MEASUREMENT
 FINDINGS: MARKED ATROPHY OF (L) UE
MM. PT IS UNABLE TO MEASURE THE (L)
UE D/T MM CONTRACTURE.
FUNCTIONAL
ASSESSMENT:
SELF CARE
EATING 4

GROOMING 4
BATHING 3
DRESSING UPPER 3
DRESSING LOWER 3
TOILETING 3
TRANSFER
BED WHEELCHAIR 4
TOILET 4
LOCOMOTION
WALKING OR WHEELCHAIR 6
STAIRS 5
COMMUNICATION
COMPREHENSION 1
SOCIAL COGNITION
MEMORY 1
LEGEND OF FIM
7 Complete Independence
6 Modified Independence
(device)
Helper- Modified Independence
5 Supervision
4 Minimal Assistance
3 Moderate Assistance
Helper- Complete Dependence
2 Maximal Assistance
1 Total Assistance or not
testable
• PT IMPRESSION: THERE IS A THROMBUS
FORMATION IN ® MCA AFFECTING THE
PARIETO-OCCIPITAL CORTEX OF THE
DOMINANT HEMISPHERE WHICH TYPICALLY
PRODUCES APHASIA, (L) UE SPASTIC
HEMIPARESIS AND SENSORY LOSS OF THE (L)
SIDE OF THE BODY WITH THE (L) FACE AND (L)
UE IS MORE INVOLVED THAN THE LE.
• REHAB POTENTIAL: THE POTENTIAL OF THE
PATIENT WILL BE GOOD IF PT WILL FOLLOW
THE HOME INSTRUCTIONS GIVEN SUCH AS
STRENGTHENING THE ® UE TO COMPENSATE
FOR THE MOTOR AND SENSORY LOSS OF THE
(L) UE. PT SHOULD ALSO BE CONDITIONED NOT
TO NEGLECT THE (L) UE. THE GOAL OF THE PT
MANAGEMENT IS TO
PROBLEM LIST
1)(L) HEMIPARESIS C GREATER EXTENT TO
UE
2)GR 3 SPASTICITY OF THE 9L) UE
3)ABNORMAL POSTURE
4)MOOD DISTURBANCES
5)POOR EXECUTIVE-FUNCTIONING SKILLS
AND JUDGEMENT
6)SLURRED SPEECH
LTG
1)TO RESTORE (N) ADL IN 20 TX SESSIONS
2)TO WORK TOWARD ATTAINING ACTIVE
MOVEMENTS
3)TO PREVENT COMPLICATION SUCH AS
CONTRACTURES
4)TO BE VERSATILE
5)TO ESTABLISH PT INDEPENDENCE
6)TO ADDRESS PTS DEPRESSION (REFER
TO PSYCHOLOGIST)
STG
1) TO IMPROVE ADL IN 10 TX SESSIONS
2) TO LESSEN SPASTICITY ON (L) UE IN 10 TX SESSIONS
3) TO STRENGTHEN ® UE, LE
4) TO ASSESS SPEECH PROBLEM (REFER TO SP)
5) TO ENCOURAGE SLOW AND CONTROLLED
MOVEMENTS
6) TO STRENGTHEN (L) HIP FLEXORS AND (L) KNEE
FLEXORS
7) TO HELP PT MOVE IN FUNCYTIONAL ATIVITIES C (N)
PATTERN OF MOVEMENTS
8) TO PROVIDE REPETITION SO THAT (N) PATTERNS OF
BEHAVIORS ARE LEARNED
9) TO EDUCATE THE FAMILY MEMBERS AS WELL AS THE
PT HIMSELF
P:
1)CONTRACTURE ON (L) UE -- US ON THE
9L) UE USING CONTIONUIOS MODE X I HZ
X 1 W/CM2 X 20 MINS, PROME OF ELBOW
TOWARD EXTENSION X 10 REPS X 3
SETS
2)MM WEAKNESS AT (L) LE – PRE ON (L)
HIP JT TOWARD FLEXION AND
EXTENSION USING BLUE THERABAND X
10 REPS X 3 SETS BID
3)MM SPASTICITY OF (L) UE – HMP ON (L)
UE X 20 MINS
HOME INSTRUCTION
1) EDUCATE FAMILY MEMBERS IN UNDERSTANDING OF
HOW TO ASSIST PT TO BE FUNCTIONAL
2) AVOID PT TO BE FEEL HELPLESS OR DISABLED
3) WHEELCHAIR MANAGEMENT ON CURBS AND OTHER
UNEVEN SURFACES FOR TRAINING
4) HOME EXERCISE PROGRAM:
5) PROME ON (L) UE TOWARD AP ON ALL PLANES X 7
REPS X 3 SETS
6) USE OF SQUEEZE BALL ON (L) HAND X 5 REPS X 3
SETS X 20 SEC REST INTERVAL
7) STRENGTHENING OF ® UE USING 500ML WATER
FILLED BOTTLE X 10 REPS X 3 SETS BID