Patient's Name: Annetjie Mnisi
Age: 76 yrs
Diagnosis: Left CVA
Occupation: Pensioner
Date of evaluation:13th and 15th April 2010
Name of Supervisor: Mr T Matswiki
Name of Student: Corrine Sheppard
Subjective evaluation:
Present Medical History:
The patient reported that she was sleeping and when she awoke the next morning, she was unable to get out of bed due to paralysis of the right upper limb and severe weakness of her right lower limb(The incident occured mid November 2009).Her family took her to Elim hospital where she was admitted for a month.
Past Medical History:
The patient has not been to a hospital for any serious medical treatment prior to the latest incident. She does however have a long history of hypertension.
Lifestyle and Socio-economic History:
The patient is living with her daughter, son-in-law, and three grandchildren in a four bedroom brick house in the watervaal community (Approximately 12 km from Elim hospital). Her daughter is a police officer and is the breadwinner of the household.
The patient has three caregivers namely the house help who comes in 5 days a week and her two grandchildren (A 18yrs old girl and a 13yrs old boy).
The patient has no history of smoking or drinking alcohol. The patient use to enjoy going to church, shopping and visiting her other daughters who live in the nearby communities. She is no longer able to do these activities due to her functional limitations.
Medication:
She is currently not taking any medication. This is a concern as she is not managing her hypertension and has a chance of having another stroke.
Home Environment:
Internal
The toilet and bath tub is inaccessible to the patient due the lack of space.The tiles in the lounge and passageway are slippery which is a potential hazard to the patient as this may lead to her falling.
The basin in the bathroom is unstable and is also a hazard to the patient as she tends to lean on it when she enters the bathroom. There is a mat on the one side of the patients bed and the patient struggles to get passed the mat(Hazard). The patient is currently using a bucket as a toilet when she needs to go at night. This is ineffective and she reports that it is difficult and she struggles.
External
There are two large steps at the front (kitchen) entrance of the house. The washing line is also in the way as it runs near the front entrance. The garden is uneven in certain places especially at the front entrance. The garden furniture will block the way and may need to be moved at a later stage. The back door has two small step and there an even cemented pathway. This is the exit point of choice.
Activities of daily living:
The patient wakes up in the morning and needs assistance when getting dressed. She is then helped to the lounged (supported walking) where she spends most her day watching television. She requires assistance to go to the toilet (supported walking) and receives food and cooldrink from the house help.She unfortunetly does not go outside and sit in the sun or do any other exercises during the day. At night she requires help to get in and out of the bath and uses a wash bucket for toilet relief during the night.
The Barthel index was used to assess her functional status (Still to be attached)
Patient's Expectations:
My patient wants to be able to walk independently.
Caregiver's Expectations:
They want the patient to be able walk indepentently and to grab objects with both hands. they want her to be more functional so that they don't have to help her with so many activities of daily living.
Caregiver's Role:
The caregivers help her to get in and out of bed. They help her dress, bath, provide her with food and assist her in getting to the toilet in the day. She is very dependant on them and needs assistance in most activities of daily living (ADL).
Objective EvaluationInitial Observation:
The patient was seated in the TV room in a forward flexed position (sloughed in her chair. The patient seemed quite depressed.
Communication:
The patient was able to communicate with me fairly well speaking english. Her home language is Shangaan. She has no apparent speech impairment.
Posture:
The right arm was in an adducted postion with her forearm flexed slightly on her lap in a fully pronated position. The fingers were all flexed in a fist. Her right shoulder is depressed and the scapula is protracred and externally rotated. The patients right shoulder is subluxed (sulcus sign present) and the patient reported that she is experiencing shoulder pain. The trunk was in forward flexion and rotated to the left. The right foot is excessive plantarflexion.
Muscle tone:
The patient has increased muscle tone on the right elbow extensors (Grade 2 modified Ashworth scale) and a slight increase in muscle tone of the right knee flexors (i.e. hamstrings - Grade 1 modified Ashworth scale). The right scapula has increased tone (grade 2 Mod Ashworth) when protractin the scapula.
Passive ROM:
The patient has a right elbow extension contracture.
The right foot has 12 degrees of dorsiflexion (Firm end feel - shortening of the Tibialis anterior).
Active Rom:
The patient has paralysis of the right wrist and hand. The forearm flexors are extremely weak (Grade 2- Oxford grading) and only able to acvtively flex her forearm 10 dergrees in the inner range (ROM 15 - 25 - 150).
Co-ordination testing:
The patients was able to perform the finger-to-nose and heel-to-shin test without difficulty. No signs of dysdiadochokinesia (tested on the unaffected upper limb).
Proprioception:
She has decreased proprioception in the left and right hips. The prioprioception of the knees is good.
Balance:
In sitting the patient has good static balance but dynamic balance is decrease as she struggles to reach for objects on the affected side. Her static and dynamic balance in standing is poor and she is unable to stand upright without support.
A Berg balance scale has been used to assess her balance status (still to be attached).
Berg balance scale:Item Description Score (0 -4)
Sitting to standing 1
Standing unsupported 0
Sitting unsupported 4
Standing to sitting 1
Transfers 1
Standing with eyes closed 0
Standing with feet together 0
Reaching forward with outstretched arm 0
Retrieving object on floor 0
Turning to look behind 0
Turning 360 degrees 0
Placing alternate foot on stool 0
Standing with one foot in front 0
Standing on one foot 0
Total 7 / 56
Conclusion of findings:
The patient has poor balance which has contributed to poor functional independancy.
< 20 points indicates that the patient is wheelchair bound
Functional Assessment:
The Barthel Index:Activity Score
Feeding 5
Bathing 0
Grooming 5
Dressing 0
Bowels 10
Bladder 10
Toilet Use 5
Tranfers 10
Mobility 10
Stairs 0
Total 55 / 100
Conclusion of findings:
Gross and Fine motor skills:
The patients is unable to use her right hand (Dominant hand) and has to now use the left hand to perform ADL. She is learning how to do tasks such as looseninng buttons , drinking from a cup and grasping objects with her left hand. Her gross and fine motor control with her left hand is reasonable but there is room for improvement.
Hearing and Vision:
This is good and both are intact. She is able to localise sound around both ears and can follow objects in all for quadrants of the visual field.
Reflexes:
She has an increased right knee jerk and a slightly decreased left knee jerk.
Please note: Still to be completed
