Lets take a look at this case study from a typical stroke presentation 👇

Presenting Complain: Inability to use the Left upperlimbs and lowerlimbs Secondary to a Left Hemispheric CVA with associated slurred speech and facial deviation.

Now pay attention

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History of presenting complain: Now he was apparently healthy and well until about 5 days ago when He got up to urinate around midnight and noticed He couldn't lift his right hand and leg when He tried getting off the bed. Now there was no loss of consciousness, convulsion or vomiting during the event.

There is no preceeding history of stroke in the family. He was subsequently taken to the hospital and admitted in accident and emergency Unit.

He has being referred for Physiotherapy on account of the above stated presentations.

Past medical history

He is not a sickle cell patient and has no blood disease or infection

He was diagnosed of hypertension about 2 years ago, he was not drug compliant, neither was he clinic compliant.

He is not athmatic and had no known cardiopulmonary conditions

He is not diabetic, recent blood sugar level reads 4.2mmol/L

He is not epileptics, and definitely has no proceeding history of convulsion, seizure or abnormal brain activity.

He has no known history of peptic ulcer disease and inflammatory bowel disease.

He has no preceding History of admission on account of stroke or any other medical conditions

Drug History : Tab Rosvastatin, IV Amlodipine, Vit C, Vasoprin

Surgrocal History: None (He never had any form of surgery done)

Family and Social History: He is a 77 year old civil servant . He is married in a monogamous setting and has 3 Children. He lives in a duplex with his wofe and children. He smokes and drinks alcohol regularly.

Communication

Cognition
-Limited attention span
-He exhibited Delayed response to questions and motor commands

Language
-Patient has difficulty expressing himself clearly( Expressive Aphasia).

We have the expressive aphasia which is due to an affectation of the broddmans area .

We also have the receptive aphasia which is due to an affectation to Wernicke's area .

Now he understands, but has trouble expressing and relaying information.

Observation and Examination: He was met in supine-lying with an IV-line tube attached on the Lt dorsum of the hand. Pt is conscious and not in any obvious respiratory distress.

Vitals

BP- 135/78mmHg (notice that his blood pressure here was almost normal due the fact that he has been placed on antihypertensive - amlodipine )

PR- 85bpm
RR- 21cpm
SPO2- 96%

GCS- 14/15
Eye opening - 4
Best Verbal Response - 5
Best Motor Response - 5

Segmental Examination

Head and Neck

The angle of the mouth is deviated to the left
Weak eye closure of the right eye

Thorax and Abdomen

No abnormality detected

Right upperlimb
-- Muscle bulk is preserved
-- Muscle Tone - Flaccidity
-- Sensation- Impaired
-- Pain - Mild (VRS- 3/10 )
-- GMP - 0, no contraction
-- PROM - Full and Painfree
-- Swelling - Absent

Left Upperlimb
Gross Muscle power - 4/5

Right Lowerlimb

Muscle bulk is preserved
Gross Muscle power of 1/5 this actually means that there was contraction but no movement
Sensation is impaired
Passive range of motion is full and painfree
Edema and swelling is absent (mean venous return is most likely not compromised , neither is there any form of inflammation to warrant swelling)
Tendon Achilles Tightness is absent

Left Lowerlimb
GMP- 4/5 ( This means he was able to move the left lower limb against a resistance)

Radiological Findings

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There is an extensive area of hypodensity seen involving the left parietemporal regions and occipital regions with surronding perilesional edema. There is associated mass effect as evidenced by narrowing of the ipsilateral lateral ventricles.

Radiological Impression is extensive acute left cerebral Ischaemia in the vascular territories of the Mid cerebral artery, Anterior Crrebral Artery and posterior Cerebral Artery.

Now from the report of the radiograph there would be a need to assess him as regards his memory just to make sure no stone is left unturned . And dont forget that he has trouble expressing himself

Remember that the parietal lobe is responsible for short term memory which enable things like solving mathematical problems , while the temporal lobe is responsible for long term memory.

To assess long term, he can be asked the name of his wife and children even things like the organisation where he works .

Clinical Impression
Right Hemiplegia Secondary to Left Hemispheric CVA.

Functional Status
-Pt cannot turn in bed
-Pt cannot sit in bed
-Pt cannot stand
-Pt is maximally dependent in ADLs

Analysis of Findings
-Weakness of the Right Upperlimbs and lowerlimbs muscles
-Sensation is impaired on the Rt side of the body.
-There is mild facial paresis of the Rt side of the face. This is definitely an Upper Motor Neuron lesion form of facial palsy, how? Just check if he can wrinkle the forehead, which in this case he can if he can wrinkle is forehead it a confirmatory diagnosis that the presentation is UPPER MOTOR NEURON related

-Pt is not ambulant and dependent on caregiver in activity of daily living.

Plan

To strengthen the weak muscles of the Right Upperlimb and Lowerlimb
To improve sensation and awareness of the Rt side of the body
To improve patient mobility in bed
To correct facial paresis and inprove facial symmetry
standing and walking reeducation
Gait-retraining and gait reeducation
Patient and Caregiver education

Interventions

-Passive Mobilization to the Rightt Upperlimbe and Lowerlimbs
-Therapeutic Positioning, there is something we call proper positioning of stroke patients, this help to prevent other musculoskeletal complications

Tactile stimulation this will certainly help to preserve muscle integrity and restore sensorial activities
Auto-assisted exs to the ULs and LLs
Bridging exercises
Weight bearings on affected limbs.
Rolling from side to side.
Facial exercises
Free active Exercises to the bilateral upperlimbs and lower limbs
Sitting re-education in bed
Standing re-education
kineosotaping to correct facial paresis

Now the above is a physiotherapy based rehabilitation approach to left hemispheric ischaemic CVD, involving assessment, examination, analysis of finding, planning then intervention.

Thanks you so much for reading this far, I hope you have been able to gain one or two things.