Physio neuro initial template

Physiotherapist Note - 1 November 2024 Aim - To assess current mobility and functional limitations following stroke. - To establish patient-centred goals for rehabilitation. Consent was obtained for the session and for the use of Heidi AI Health Scribe. Patient's wife, Mrs. Sarah Davies, and Dr. Thomas Kelly (GP) were present during the session. Subjective History of Presenting Complaint Patient, Mr. John Smith, aged 68, presents with right-sided hemiparesis and significant balance impairment following an ischaemic stroke in April 2024. He reports difficulty with walking, self-care tasks, and fear of falling, which restricts his participation in community activities. Mr. Smith also has well-controlled type 2 diabetes (diagnosed 2010) and hypertension (diagnosed 2005), both managed with medication. There are no other significant comorbidities impacting his current rehabilitation. The stroke diagnosis was confirmed via MRI scan at St. Jude's Hospital on 15 April 2024. He was discharged from inpatient rehabilitation on 10 June 2024. Since discharge, he has been receiving weekly home physiotherapy input focusing on gait re-education and strengthening. He also attends occupational therapy twice a week for ADL retraining and sees a speech pathologist for mild dysphagia management. PMHx - Ischaemic stroke, April 2024 - Type 2 Diabetes Mellitus, diagnosed 2010, managed with Metformin 500mg BD - Hypertension, diagnosed 2005, managed with Amlodipine 5mg OD - Left knee meniscectomy, 2015, full recovery Imaging Results - MRI Brain (16 April 2024): Demonstrated an acute infarct in the left middle cerebral artery territory, consistent with clinical presentation. Medication History - Metformin 500mg, twice daily - Amlodipine 5mg, once daily - Aspirin 75mg, once daily - Atorvastatin 20mg, once daily - Vitamin D supplement, once daily Occupational Therapist (Ms. Emily Green) and Speech Pathologist (Mr. David Lee) are also involved in the patient's care. Social History Mr. Smith lives with his wife in a single-story house. He was a retired accountant and enjoyed gardening and playing golf prior to his stroke. He feels frustrated by his current limitations and relies heavily on his wife for support with daily tasks. His wife is his primary carer and reports feeling overwhelmed at times. He is keen to regain independence to participate in family outings and manage his garden again. He previously drove but has been advised not to due to his stroke. His daily routine involves waking, assisted showering, dressing, and then spending most of the day in the living room, often watching television or reading. He attempts short walks around the house with his wife's supervision. ADLs Requires moderate assistance with showering and dressing due to right arm weakness and balance issues. Can feed himself independently, though some fine motor challenges are noted with cutlery. Toileting is independent but transfers require supervision. Continence is intact. Balance is significantly impaired, particularly in standing. He exhibits a posterior lean and struggles to maintain a stable base of support without external aid or supervision. Postural control is poor, with noticeable sway during static standing. Functional use of his right upper limb is limited, primarily to gross motor tasks with reduced dexterity. Left upper limb is functionally intact. His right lower limb is weak, leading to foot drop and impaired knee control during gait. Mobility Current mobility involves short distances indoors using a four-wheeled walker with supervision. He shuffles his feet and has a slow, antalgic gait pattern. He can walk approximately 10 metres before needing to rest due to fatigue and fear of falling. Bed transfers are performed with minimal assistance from his wife. Chair transfers (armchair to dining chair) require supervision and verbal cues for proper technique. He uses the armrests for support. Stairs are not currently negotiated independently. He requires significant assistance and supervision to manage a single step. Endurance is significantly reduced, becoming fatigued after 5-10 minutes of continuous activity, such as walking or standing. Falls Mr. Smith has had two falls since discharge from hospital. The first occurred attempting to stand from his armchair without his walker, resulting in a minor bruise. The second occurred when turning quickly in the kitchen, leading to a bump on his head. Both falls were unwitnessed by his wife. He reports a fear of falling, which has impacted his confidence and willingness to mobilise independently. IADLs Requires full assistance with medication management (his wife pre-sorts his medications). Finances are managed by his wife. Unable to assist with meal preparation or housework. Gardening, phone use, and shopping are currently not possible due to his physical limitations and dependency. Participation Unable to drive. Relies on his wife for transport. Hobbies like gardening and golf are currently not possible. Social interactions are limited to family visits at home due to mobility restrictions. Support His wife provides full-time informal support, assisting with personal care, mobility, and household tasks. This includes assistance with showering, dressing, meal preparation, and managing appointments. She is available at all times. Formal support includes weekly physiotherapy and twice-weekly occupational therapy. Impairment Level Concerns Reports adequate nutrition. Mood is generally stable but expresses frustration regarding his limitations. Sleep is reported as fair, occasionally interrupted by pain in his right shoulder (8/10 at worst, dull ache). Hearing is good with hearing aids. Vision is corrected with glasses, no reported issues. Home Environment - Single-story dwelling with two steps at the front entrance and one step at the back. - Equipment: Uses a four-wheeled walker and a shower chair. - Shower is a walk-in shower, but requires a grab rail for safety. - Toilet is standard height, which he finds difficult to use independently. - General layout is open plan, but corridors are narrow. Suitability of current equipment: The four-wheeled walker is appropriate for indoor mobility, but a grab rail in the shower is needed. The standard height toilet presents a challenge for independent transfers. History of previous equipment trials or rejections: Previously trialled a walking stick but found it unstable due to his hemiparesis. Preferred the four-wheeled walker for better support. Known barriers in the home environment: Narrow doorways in the bathroom, steps at entrances, and a lack of grab rails in key areas. Previous home modifications or anticipated future needs: No previous modifications. Anticipated needs include grab rails in the bathroom, a raised toilet seat, and potentially a ramp for the front entrance. No specific cultural or language considerations were identified. Mr. Smith and his wife are fluent in English. Communication and Cognition Mr. Smith has a good level of understanding and can follow multi-step instructions. He is able to participate in conversations and express his needs clearly. No significant behavioural considerations or sensory needs were noted. Pain Reports intermittent dull ache in his right shoulder, 3/10 at rest, increasing to 8/10 with movement. Triggers include reaching overhead or sustained positioning. Manages with paracetamol 500mg PRN, which provides some relief. Patient Goals - Short-term goals: - Be able to walk 20 metres independently with his walker indoors. - Transfer from bed to chair with minimal assistance. - Shower with supervision only. - Long-term goals: - Return to gardening with adaptations. - Walk independently outdoors with his walker for short distances. - Reduce reliance on his wife for daily tasks. Reason for physiotherapy referral is for ongoing rehabilitation to improve mobility, balance, and functional independence following his stroke, as well as falls prevention. The patient and carer demonstrate a good understanding of the condition and the rehabilitation process, acknowledging that recovery is a gradual process. Functional concerns primarily revolve around safe ambulation, independent transfers, and participation in previously enjoyed activities due to right-sided weakness and balance deficits. Mr. Smith previously underwent an intensive inpatient rehabilitation program. He found it challenging but beneficial. Hopes to regain enough independence to visit local shops and spend time in his garden. Concerns include falling again and becoming a burden to his wife. Objective Assessment * Posture: Flexed posture with right shoulder protraction and mild trunk asymmetry. Guarded gait pattern with reduced right arm swing. * Gait: Slow, shuffling gait with right circumduction and foot drop. Uses a four-wheeled walker with a wide base of support. Takes small steps. * Assistive device use: Proficient with four-wheeled walker, but relies heavily on it for support. * Alignment: Appears generally aligned in sitting, but right pelvic hike noted in standing. * Skin integrity: Intact, no pressure areas noted. * Functional observations: * Transfers: Bed to chair: requires verbal cues for sequencing and min A for stand-pivot-sit. Chair to standing: requires mod A to initiate and maintain standing balance. * Bed mobility: Rolls to left independently, rolls to right with mod A. Supine to sit: requires min A for leg placement. * Sit to stand: Mod A, takes multiple attempts, uses armrests. Stand to sit: Controlled with mod A. * Walking: Ambulated 10m with four-wheeled walker and supervision. Gait speed 0.2 m/s. Significant right foot drop noted. * Stairs: Unable to ascend/descend single step independently. * Splint/orthotic use: Uses an ankle-foot orthosis (AFO) on the right for foot drop. * ROM and flexibility findings: Right ankle dorsiflexion limited to 0 degrees (normal 20 degrees) due to spasticity. Right shoulder flexion to 90 degrees with pain, abduction to 70 degrees. Left side full ROM. * Strength findings from functional or manual muscle testing: Right hip flexors 3/5, knee extensors 3/5, ankle dorsiflexors 1/5. Right shoulder abductors 3/5, elbow flexors 4/5, wrist extensors 2/5. Left side 5/5 throughout. * Balance findings including static and dynamic, eyes open and closed, and supported and unsupported: Static standing balance: Unable to stand unsupported for >5 seconds. Supported standing with walker: demonstrates significant sway and requires guarding. Dynamic standing balance: Unable to perform tandem stance or single-leg stance. Eyes open vs. closed: Balance significantly worse with eyes closed. * Mobility tests performed and results: 10m Walk Test: 0.2 m/s. Timed Up and Go (TUG) Test: 45 seconds (very slow, high falls risk). * Neurological findings including tone, reflexes, spasticity and coordination: Modified Ashworth Scale (MAS) for right ankle plantarflexors 2 (moderate increase in tone). Deep tendon reflexes: 2+ bilaterally, symmetrical. Coordination: Right upper limb shows dysmetria during finger-to-nose testing, right lower limb exhibits impaired heel-to-shin test. Fatigue tolerance or exertion response: Patient demonstrates increased shortness of breath and reports fatigue after 5 minutes of continuous walking, necessitating rest breaks. * Outcome measures used and results: * 10m Walk Test: 0.2 m/s * TUG Test: 45 seconds * Berg Balance Scale: 20/56 (indicating significant balance impairment and high falls risk) Treatment Education Patient and wife educated on safe transfer techniques, energy conservation strategies during ADLs, and the importance of regular exercise to maintain strength and mobility. Discussed the benefits of consistent AFO use for gait safety. Provided advice on home modifications for falls prevention, specifically recommending grab rails in the bathroom. Hands-On Therapy * Passive stretching to right ankle plantarflexors for 30 seconds x 3 repetitions. * Manual facilitation techniques for right hip flexion and knee extension during gait practice. * Postural correction cues provided during sit-to-stand transfers. Active Therapy/Exercises * Sit-to-stand training: 3 sets of 8 repetitions, focusing on forward lean and hip drive. * Resistance exercises: Theraband exercises for left hip abduction and knee extension (3 sets of 10 repetitions each). * Balance retraining: Supported standing balance on foam surface (3 x 30 seconds) with verbal cues for weight shifting. * Gait training: 15 minutes of walking practice with four-wheeled walker, focusing on increasing step length and reducing right circumduction. Rest breaks taken every 5 minutes. * Mobility practice: Bed mobility retraining focusing on independent rolling. Analysis Key impairments include right-sided hemiparesis, significant balance deficits, right ankle plantarflexor spasticity, and reduced endurance. Functional limitations manifest as difficulty with independent transfers, ambulation, and self-care tasks. Strengths include good cognitive function, strong motivation, and robust family support. Clinical diagnosis: Post-stroke right hemiparesis with associated balance impairment and functional limitations. The disability significantly impacts Mr. Smith's participation in previously enjoyed hobbies such as gardening and social activities, leading to feelings of frustration and increased dependency. Identified risks include high falls risk due to poor balance and fear of falling, and caregiver burnout for his wife. Plan * Recommended physiotherapy focus areas: * Improve dynamic balance and gait speed. * Strengthen right lower limb and trunk musculature. * Progress independent transfer ability. * Falls prevention education and home modification recommendations. * Caregiver education on safe handling techniques. Recommended frequency and duration of therapy: Two sessions per week for the next 12 weeks to consolidate gains and progress towards functional goals. Recommended equipment trial or review: Trial of a raised toilet seat. Review current AFO fit and consider potential alternatives if spasticity increases. Plan to liaise with the support team or arrange a case conference: Will communicate with occupational therapist regarding home modification recommendations and ADL progress. Will arrange a family meeting with GP and OT to discuss long-term care planning and caregiver support. * Education topics to be addressed in future sessions: * Advanced falls prevention strategies. * Fatigue management techniques. * Home exercise program progression. * Community exercise programs. Home exercise program initiation and planned progression: Initiated with ankle pumps, knee flexion/extension in sitting, and supported standing balance exercises. Will progress to unsupported balance and functional strengthening as tolerated. * Referral suggestions: * Local falls and balance clinic for specialist assessment. * Social worker for caregiver support services.