Ambulation Disturbance ec Stroke

(1)

IDENTITY (June 17^th, 2022) ABE/MIC/ dr. NS, Sp. KFR-K

Name : Mrs. A

Age : 71 years old

Sex : Female

Religion : Moslem Marital Status : Married Address : Surabaya Occupation : Housewife Education : Junior Highschool

Referred from Neurology OPC of RSUD Dr. Soetomo with Post Stroke Trombotik (April 2022) + Hipertensi + Status Focal Onset Sinistra to Bilateral tonic clonic seizure

AUTOANAMNESIS

II.1. Chief Complaint: Nyeri lutut kiri > kanan dan kelemahan tubuh sisi kiri

II.2. History of Present Illness: The patient complained pain on her knees (left > right) and her left ankle, felt since 1 year ago, worsened within 1 month ago, intermittent dull pain, not radiating, no numbness, stiffness on the morning

< 30 minutes (+), crepitation (+), the pain aggravated with walking for 50 meters, standing, relieved with sitting and resting. WBS: 7, and WBS: 5 when relieved.

2 months ago, she had seizure on her left hand and leg, lasted for ± 2 minutes, appeared for ± 5x/day, appeared when she was sitting cutting the onions, she was conscious during the seizure. She was brought for massage, after 3 days the symptoms worsened (longer duration of seizure and higher frequency), and weakness on left extremities (+), dysarthria (-), skewed face (-), numbness on left (+). Went to Soetomo Hospital Emergency Department, hospitalized for 7 days in Seruni A, the seizure last appeared on 8^th April 2022. After being discharged, she had already been able to mobilize independently without ambulation aid, but after 1 month, she felt pain on her both knees and left ankle. When to Neurology OPC for routine examination, was referred to PM&R OPC for further evaluation and treatment.

II.3. History of Functional Ability: The patient has needs help to prepare her food, but able to eat independently, able to bath, groom, and dress independently. Sometimes need assistance to go to the toilet, ambulating using tripod, but she never go up and down stairs. No fecal and urinary incontinence.

II.4. History of Medication and Rehabilitation: Currently she got the medication from Neurology OPC of Phenytoin 2x100 mg, Clopidogrel 1x75mg, Folic acid 2x1, Simvastatin 1x20mg, VitaminB1B6B12 1x1, Gapatentin 2x100. From Internal Medicine OPC of Novorapid 3x 14IU, Levemir 20 IU (night), and Candesartan 1x8mg. She has been consulted to PM&R Department when hospitalized on April 2022.

II.5. History of Past Illness:

 Hypertension (+) Since 5 years ago, currently controlled

 Diabetes mellitus (+) Since 5 years ago, currently uncontrolled

 Dylipidemia (+)

 Stroke (+) 1^st Attack 10 years ago, only slight weakness but able to do all activities independently

 Coronary artery disease (+) 2018, post Stent.

 Cancer (-)

 Smoking (-)

II.6. History of Hobby and Work: She likes to watch TV “sinetron”, within the last 2 months she didn’t do her house chores. Being helped by her house assistant.

II.7. History of Psycho-Social-Economic: The patient lives with her First son (50 yo, Entrepreneur, Highschool), her daughter’s wife and her grandchildren (20 yo, University student). She lives in a 1-floor building, she uses the sitting toilet. But currently she was accompanied by her 6^th son to the hospital for examination.

II.8. Family History: There is no family with the same symptoms.

II.9. Patient’s Expectation: She hopes that her pain relieved and better motor strength.

(2)

(3)

PHYSICAL EXAMINATION III.1. General Status

GCS E4 V5 M6 BP: 120/80 mmHg (MAP 93.33), HR:96x/min, RR: 12x/min, Temp: 36.6^oC, SpO2: 99%

Height: 150 cm, Weight: 50 kg, BMI: 22.2 kg/m2 (Normal)

Posture: forward head, rounded shoulde. Dominant extremity: Right-handed. Ambulation: dependent with wheel chair, at home with tripod.

Head and neck :

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-) Cor : S1-S2 normal, regular, murmur (-), gallop (-)

Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-) Abdomen : Soefl, peristaltic (+), tenderness (-)

Extremities : Warm acral (-|-), cyanosis (-), edema (-|-) III.2. Head/Neck/Trunk,

Movement ROM Muscles MMT

Neck Flexion (0-45⁰) Extension (0-45⁰) Lateral flexion (0-45⁰) Rotation (0-60⁰)

F/F F/F F/F F/F

Flexor Extensor Lateral flexor Rotator

5/5 5/5 5/5 5/5 Trunk Flexion(0-85⁰)

Extension (0-30⁰) Lateral flexion(0-35⁰) Rotation(0-45⁰)

F/F F/F F/F F/F

Flexor Extensor Lateral flexor Rotator

5/5 5/5 5/5 5/5 Neuromuscular :

Cranial Nerve Right Left Reflex / Special Test

Cranial Nerve I Normal Normal

Cranial Nerve II 3/60 3/60 Direct Light Reflex (+|+)

Indirect Light Reflex (+|+)

Cranial Nerve III Normal Normal

Cranial Nerve IV Normal Normal

Cranial Nerve V Normal Normal

Cranial Nerve VI Normal Normal

Cranial Nerve VII Normal Normal

Cranial Nerve VIII Normal Normal

Cranial Nerve IX Paresis Normal

Cranial Nerve X Paresis Normal

Cranial Nerve XI Normal Normal

Cranial Nerve XII Paresis UMN Type Normal III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-)

Feel : warmth (-|-), tender point (-|-), crepitation (-|-) Move : pain (-|-), shoulder subluxation dextra (-) Neuromuscular :

- Spasticity : -/+ MAS Elbow Flexor MAS 1+

- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2) - Pathological reflex : Hoffmann (-|-), Tromner (-|-)

- Sensorics : 100/70

- Rigidity : -

(4)

Region Movement ROM Movement MMT Shoulder Flexion(0-180⁰)

Extension (0-60⁰) Abduction(0-180⁰) Adduction(0-45⁰)

Internal Rotation (0-90⁰) External Rotation (0-70⁰)

F/F F/F F/F F/F F/F F/F

Flexor Extensor Abductor Adductor Internal Rotator External Rotator

5/5 Impression D>S

Elbow Flexion(0-135⁰) Extension (135º-0) Pronation (0-90⁰) Supination(0-90⁰)

F/F F/F F/F F/F

Flexor Extensor Pronator Supinator

5/5 Impression D>S Wrist Flexion (0-80⁰)

Extension (0-70⁰) Radial deviation (0-20⁰) Ulnar deviation (0-35⁰)

F/F F/F F/F F/F

Flexor Extensor Radial Deviator Ulnar Deviator

5/5 Impression D>S Fingers Flexion

Extension Abduction Adduction

F/F F/F F/F F/F

Flexor Extensor Abductor Adductor

5/5 Impression D>S

III.4. Lower Extremities Region.

Move : pain when move (+|+) Neuromuscular :

- Deep Tendon Reflex : KPR +2|+2; APR +2|+2 - Pathological reflex : Babinski (-|-), Chaddock (-|-)

- Sensorics : 100/70 (Above mid tibia), 90/60 (Mid tibia to toes) - Propioceptive : Able/Poor

- Spasticity : (-|-) - Special test : PGT (+|+) - Q-Angle WB & NWB : 5/5^oto valgus - Apparent leg length : 69/69cm

- True leg length : Femur: 39cm, Tibia 32cm (D&S)

- Circumference : Thigh (10cm above MTP): 37/37, MTP: 30/30cm, Calf (10cm below MTP): 30/30cm

Region Movement ROM Movement MMT

Hip Flexion(0-125⁰) Extension (0-30⁰) Abduction (0-45⁰) Adduction (0-20⁰) Internal Rotation (0-45⁰) External Rotation (0-45⁰)

F/F F/F F/F F/F F/F F/F

Flexor Extensor Abductor Adductor Internal Rotator External Rotator

4/4 Impression D>S

Knee Flexion (0-135⁰) Extension (135º-0)

F/F F/F

Flexor Extensor

5/4p 5/4p Ankle Dorsiflexion (0-20⁰)

Plantarflexion (0-50⁰) Eversion (0-15⁰) Inversion (0-35⁰)

F/F F/F F/F F/F

Dorsiflexor Plantarflexor Evertor Invertor

5/5 Impression D>S Big Toes Flexion

Extension

F/F F/F

Flexor Extensor

5/5 Impression D>S

Toes Flexion

Extension

F/F F/F

Flexor Extensor

5/5 Impression D>S

(5)

III.5. Functional Status

Balance : Sitting balance static good dynamic good, standing balance (static and dynamic) is poor.

Transfer : lying to sitting, sitting to standing able with minor help.

Count test : 9

Chest expansion : 2,5/2,5/2,5 cm

Cerebellum : finger to nose (+|+), dysdiadochokinesia (-|-), heel to shin (+|+) Barthel Index : 70

Feeding 5/10 Bladder 10/10

Grooming 5/5 Toilet use 5/10

Bathing 5/5 Mobility 10/15

Dressing 10/10 Transfer 10/15

Bowel 10/10 Stairs 0/10

MOCA-INA : 8 (Cognitive Impairment) Star Cancellation test : Able

Sensory Extinction test : Able

SARC-F : 6 (Sarcopenia)

Fear of fall : 45/64 (Severe)

GDS : 10 (Depression)

FRAX Score : Major Osteoporotic 13%, Hip Fracture 3.7%

SUPPORTING EXAMINATION CT Head (April 8^th2022) :

 Subacute ischemic cerebral infarction di corona radiata kanan

 Sinusitis ethmoidalis bilateral Laboratory (April 9^th 2022):

 Glukosa puasa: 278 (N: <150)

 HbA1C: 17,9 (N: 4.3-6.0)

 Asam Urat: 7.4 (N: 2.6-7.2)

 Kalsium: 8.8 (N: 8.5-10.1)

 Fosfat: 2.8 (N: 2.5-4.9)

 Kolesterol Total: 266 (N: 0-200)

 Trigliserida: 97 (N: 30-150)

 HDL: 53 (N: 40-60)

 LDL: 214 (N: 0-99) Laboratory (May 12^th 2022):

 Glukosa puasa: 129 (N: <150)

 HbA1C: 14,4 (N: 4.3-6.0)

 SGOT: 16,0 (N: 4.3-6.0)

 SGPT: 12.0 (N: 0-55)

 Albumin: 3.49 (N: 3.4-5.0)

 BUN: 21.0 (N: 7-18)

 Kreatinin Serum: 0.81 (N: 0.6-1.3)

 Kalium: 4.9 (N: 3.5-5.1)

 Natrium: 144.0 (N: 136-145)

 Klorida: 102 (N: 98-107)

 Kolesterol Total: 261 (N: 0-200)

 Trigliserida: 104 (N: 30-150)

 HDL: 72 (N: 40-60)

 LDL: 162 (N: 0-99)

(6)

EEG (April 12^th 2022)

 Impresi: EEG abnormal II (pasien penurunan kesadaran 100%),

 BSA (Background slow activity)

 CSA (Continuous slow activity) general

 Korelasi klinis: EEG saat ini perekaman abnormal, mengindikasikan adanya ensefalopati difus derajat sedang yang bisa berpotensi epileptogenic general.

PROBLEM LIST

o Bilateral Knee Pain (S>D)

o Post stroke Infarct 2^nd Attack (2 Months) o Post Seizure

o Cognitive impairment o Depression

o Geriatric Syndrome o Ambulation disturbance

o Parese of Left Nervus IX, X, XX UMN Type o Hemiparese sinistra

o Deficit sensory in left upper extremity and bilateral lower extremities o Poor standing balance

o Uncontrolled blood glucose o Hypertension (controlled) o Decreased count test o Decreased chest expansion

o Forward head and rounded shoulder posture o Fear of fall

ICF

Body Function:

b280 Sensation of pain (Bilateral knee pain) b117. Intellectual function (Cognitive impairment) b152. Emotional function (Depression)

b415 Blood vessel function (HT)

b265. Touch function (Deficit sensoric in left upper extremity, and both lower extremities) b555. Endocrine gland function (Abnormal blood glucose)

b730. Muscle Power Function (hemiparese sinistra, parese of left IX, X, XII Dextra b789. Movement functions (Difficulty in walking)

Body Structure:

s110. Structure of brain (post stroke infarct 2^nd attack, seizure, and abnormal EEG) s730. Structure of Upper Extremity (Left slight weakness, deficit sensory)

s750. Structure of Lower Extremity (Left slight weakness, and bilateral knee pain ec OA genu and deficit sensory) Activities and Participation:

d415. Maintain Body Position (poor standing balance) d450. Walking (ambulation disturbance)

d530. Toileting (Needs minor help going to toilet) d550. Eating (Needs help to prepare food) Environmental Factors:

e310. Immediate family (Family support)

e580. Health Services, System and Policy (patient covered by BPJS) ASSESSMENT

Bilateral Knee Pain ec Knee OA + Ambulation Disturbance + Cognitive Disturbance ec Post Stroke Infarct (2 Months) + Seizure on Treatment + Geriatric Syndrome + Severe Frailty + Suspect Sarcopenia + Fear of Fall + Hypertension (Controlled) + DM Type 2 (Controlled) + Depression

(7)

PROGNOSIS

Ad vitam : Dubia ad Malam

Ad sanactionam : Dubia ad Malam

Ad functionam :

- Transfer: Independent

- Ambulation : Independent with walking aid - Other ADL : Independent

Goals:

Short Term Goals:

1. Reduce pain

2. Maintain ROM and prevent contracture 3. Muscle power optimalization

4. Decrease fear of fall 5. Managed depression

6. Transfer and ambulation function independent with walker 7. Improve count test and chest expansion

Long Term Goals:

1. Indepentent ambulation and ADL 2. Prevent recurrent stroke

3. Prevent complication

4. Controlled blood glucose and hypertension (comorbids) Planning

PDx: Consult to Geriatric OPC (Psychiatry) for multidiscipline evaluation and treatment PTx:

Modality: HI TENS 100 Hz on Left knee and ankle, as patient’s tolerance, for 30 minutes Thera Exercise:

 Precaution seizure (free from seizure 2x24 hours) Stroke:

 Stable: Neurological, no worsening or decrease in consciousness

 MAP for non-hemorrhagic <130, hemorrhagic <120

 Blood Glucose: Post prandial exercise (90-250)

 SpO2: >95%

1. Posture correction

2. Breathing exercise with deep breathing 3. Chest expansion exercise

4. AROM Exercise AGA/B D/S

5. Sitting to standing exercise with stable support 6. Standing balance and tolerance exercise 7. Gait training with walker

8. Sensory resensitization OP: Walker

PMx: Clinical sign, vital sign, pain, MMT, sensory, ROM, balance, depression, fear of fall.

PEx:

1. The patient’s condition and the rehabilitation program

2. Icing for 15-20 minutes when pain, can be repeated every 2 hours.

3. Continue exercise and practice at home 4. Prevent fatigue and seizure.

5. How to use the walker

6. Continue medication from Neurology and Internal Medicine OPC.