Right upper extremity post-stroke weakness, chronic low back pain

The patient is a very pleasant 86-year-old gentleman who suffered a cerebrovascular accident on March 5, 2013. He states he had symptoms of weakness when brushing his teeth and he was unable to pickup his toothbrush. He was urgently evaluated and found to have had a stroke. No imaging studies are available at his consultation today. He comes in today to consider a course of physical rehabilitation for the arm. He has already been given two formal physical therapy prescriptions from his other treating physicians but did not initiate therapy.

He also mentions a history of chronic low back pain over the last 10 years and would like to be evaluated for that as well. He has had x-rays and MRIs but does not know where he had them performed.

ASSESSMENT:
This is an 86-year-old gentleman who suffered cerebrovascular accident on March 5, 2013 and remains on Plavix therapy. He has right upper extremity fine motor coordination issues, but has rather preserved strength in the right upper extremity. He has advanced degenerative spondylitic changes on the lumbar spine from MRI of two years ago.

IMPRESSION:
1. Right upper extremity motor weakness; status post CVA March 5, 2013
2. Advanced lumbar spondylosis including grade II spondylolisthesis at L4 on L5 and subarticular stenosis; I am unable to view the images today – please see above interpretation.
3. Chronic Plavix therapy.
4. Status post cardiac stenting.

PLAN:
I had a nice visit with Mr. today. We will get him started in some physical therapy two to three times a week over the next four weeks for his upper extremity weakness secondary to CVA. We can consider bilateral sacroiliac joint injection with a small gauge needle without compromising his daily Plavix therapy. We will consider that after four weeks of physical therapy and we will reassess next month. Obviously from the MR report of his spine, he has severe disease. He is probably not a good surgical candidate from an anesthetic perspective but a surgical opinion may ultimately be warranted.

They are fine with this conservative course of treatment and I will see him next month for follow-up.

Advertisements

Leave a Reply