Case Study Report

CASE STUDY REPORT
Patient`s Name : Anniki Mnisi
Age : 76 Years
Gender : Female
Diagnosis : Left CVA, Right Hemiplegic
Physical Address : Waterval
Occupation : Pensioner
Marital Status : Single
Caregiver : Jestinah Chauke
Date of evaluation : 02 March 2010
Name of student : Mashego S.T
Supervisor : Mr Matswiki T.M
















SUBJECTIVE EVALUATION
Present medical history
At around September 2009 the patient woke up early in the morning she wanted to go to the toilet ,then she started feeling that her right upper and lower limb were very weak and numb, she was unable to walk by herself, and by that time she was with her grand daughter, her daughter was still at work. When the daughter came back she took her to a nearby private Doctor who diagnosed her with CVA and referred her to Elim hospital where she was admitted for two weeks it was confirmed that she was a left CVA(Right hemiplegic). After two weeks she was discharged without seeing a physiotherapist.
Past medical history
She was a known hypertensive patient who was on medication before she suffered a stroke ,she was diagnosed with hypertension a long time ago but she can`t remember when and also the caregiver can`t remember, no other related medical history.
Socioeconomic history
Occupation: The patient is a pensioner, she is not a breadwinner ,the breadwinner is her daughter who is a police woman who stay with her.
Marital status : The patient is single, she was never married, she is a single mother of four children, three daughters and one son who are grown ups and they are married except the one who she stays with her in the house. Her daughter hired caregiver to take care of her and clean the house.
Home environment internal: The patient stays in a 7 roomed house builded by bricks, the toilet is inside and flushing, the is electricity and running in the house,the floor is cemented in the patient room and other bedrooms but the kitchen and the sitting room are tiles, there is enough space in the patient`s room for propelling a wheelchair and other walking aids, the patient sleeps on a double bed and the mattress is firm.
External environment: There is one step at the entrance of the house by the kitchen and also one at the front, the terrain is smooth the passage to the gate is cemented and by the sides is a lawn.
Transport and roads: The patient`s daughter usually use her car to take the patient to hospital, clinic and to town, and also a public transport is easily accessible because the taxis are running by the street every 10 minutes. T he road is a tar road and smooth.
Health facilities ; The hospital is about 4KM away from the patient `s home and the clinic is about 2KM away from the patient `s home and they are easily accessible.



Patient`s highest functional level: Feeding herself in high sitting
Patient`s expectations: To be able to walk by her self to the toilet and also to the church.
Caregiver`s expectations : The patient to be able to walk by her self to the toilet, to the kitchen and to be able to make tea for herself and to be able to perform activities of daily living without difficulty.
Caregiver`s role : To bath the patient, dress her, prepare food and assist her with toileting.

Activities of the daily living : She brushes her teeth, wash her face and feed herself with the unaffected upper limb everyday.
Habits : The patient never smoked cigarette and never drunk alcohol ever since in her life.
MEDICATION
The patient used to take antihypertensive medication from the clinic before the stroke, at the moment she is not taking any medication. The caregiver and the daughter were encouraged to take the patient for monthly BP check up. And also to collect her antihypertensive medication at the clinic
OBJECTIVE EVALUATION
General observation
The patient was found in high sitting on the couch, with the right upper limb supported by the left upper limb on the patient`s lap, the forearm in 90 degrees of elbow flexion, right shoulder slightly abducted, wrist in flexion and fingers in flexion. The right lower limb was elevated on the table with a pillow under it, there was swelling of the right lower limb.
Balance
Sitting: Static is good
: Dynamic is good
Standing: s static is poor
: Dynamic is poor
Muscle Tone
Normal for the left upper limb and lower limb
Right shoulder –slightly increased in abduction, flexion, extension
Right elbow – moderately increased
Right wrist- slightly increased
Right hip – slightly increased
Right knee and ankle are normal
Increased muscle tone of trunk muscles
Muscle strength
Right upper limb Left upper limb
Grade 1 of shoulder flexors Grade 4 of flexors
Grade 1 of shoulder extensors G rade 4 of extensors
Grade 2 of elbow flexors Grade4of elbow flexors
Grade 2 elbow extensors Grade 4 of elbow extensors
Grade 1 wrist flexors and extensors Grade 4 wrist flexors and extensors
Lower limb
Right Left
Grade 2 Grade 4
Range of motion
Decreased range of motion of the right elbow extension
Co ordination
The co ordination is poor on the upper limbs and lower limbs
For functional evaluation see the attached copy of Barthel index scale
POMES
Problem
Underlying reason
Limiting factor
Short term goal
Treatment
Inability to come from sitting to standing
Poor balance in standing.
Lack of head, trunk and hip dissociation.
Poor pelvic and trunk mobility.
Weak UL and LL strength

To re educate balance in standing, strengthen muscles of LL and reduce swelling
Rhythmic stabilisation, PNF and elevation of LL and foot pumps.
Manual strengthening exercises of unaffected limbs. Pelvic shifting and trunk mobilisations







Inability to walk independently to the toilet, kitchen and t church
Insufficient hip and knee flexion.
Lack of dissociation of the hip and knee.
Poor balance, co ordination and weakness.
Swelling on the right foot and ankles
Poor posture
To strengthen weak muscles and normalise tone and reduce swelling and improve co ordination
Strengthening exercises (PNF, resited exercises) elevation of foot and foot pumps and frenkel`s exercises.
Passive mobility exercises of the trunk hip and knee.

Inability to dress and undress herself using both upper limbs
Limited ROM of the right shoulder.
A patient lacks initiation/stimulation in most of the activities.

Pain on the right shoulder Increased tone on UL ,weakness of muscles and decreased ROM of right UL
To normalise tone, strengthen weak muscles and improve ROM of UL and relieve pain
Weight bearing exercises,compressions,autoassisted exercises,PNF,resisted exercises and stretching exercises and gentle mobs of the shoulder
Facilitation of self-care activities.
Poor posture during walking
Increased tone of the muscles of the trunk and weakness of back extensors,


To normalise muscle tone of the trunk and strengthen back extensors
Back strengthening exercises
Posture correction
Weight bearing exercises of the ULs, LLs and trunk.
Trunk mobility exercises
Pelvic tilting exercises


Long term goals
Patient to be able to walk independently to the toilet, to the kitchen to make tea for herself and to go to church, with minimal support of the quadripod.