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CASE STUDY: STROKE

CASE STUDY: STROKE. History of Present Illness. 63 y/o, male (+) HPN Weakness of right upper and lower extremities for 2 days Slurred speech. Physical Exam. Awake and can follow commands Approximately answers questions Dysartric (+) drooling Shallow right nasolabial fold

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CASE STUDY: STROKE

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  1. CASE STUDY: STROKE

  2. History of Present Illness • 63 y/o, male • (+) HPN • Weakness of right upper and lower extremities for 2 days • Slurred speech

  3. Physical Exam • Awake and can follow commands • Approximately answers questions • Dysartric • (+) drooling • Shallow right nasolabial fold • Weak gag reflex • Tongue deviated to the right on protrusion • MMT: 3/5 Right upper extremity (proximal and dista)l; 3/5 lower extremity (proximal, 1/5 right distal) • MSR UE/LE: +++ at right side

  4. On Hospital Admission • Rehabilitation program started on bedside • Discharged able to ambulate in between parallel bars

  5. After Discharge • Unable to continue outpatient therapy seession • After 5 months, (+) right shoulder and right hand pain, with spastic gait, and dragging of foot

  6. Working Impression • Cerebrovascular Accident, Ischemic with Right-sided hemiparesis and dysarthria probably due to occlusion of Left Middle Cerebral Artery or Left Anterior Cerebral artery

  7. Manual Muscle Testing Grade 5:  Patient can hold the position against maximum resistance and through complete range of motion. Grade 4:  Patient can hold the position against strong to moderate resistance, has full range of motion. Grade 3:  Patient can tolerate no resistance but can perform themovement through the full range of motion. Grade 2:  Patient has all or partial range of motion in the gravity eliminated position. Grade 1:  The muscle/muscles can be palpated while the patient is performing the action in the gravity eliminated position.  Grade 0:  No contractile activity can be felt in the gravity eliminated position

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