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I now have enough clinical knowledge to fill in the form accurately. Here is the fully completed Physical Therapy Assessment for a right-hemisphere ischemic stroke patient presenting with left hemiparesis:
PHYSICAL THERAPY ASSESSMENT - FILLED CASE
Patient: Right MCA Ischemic Stroke with Left Hemiparesis
H/O: (History Of)
Name: Mr. Rajesh Kumar | Age: 58 years | Sex: Male
Date of Admission: 10/07/2026 | Date of Assessment: 12/07/2026
Ward/Bed: Neurology Ward, Bed No. 12
Referred by: Dr. (Neurologist) for physiotherapy rehabilitation
Chief Complaint: Sudden onset weakness of left upper and lower limb since 2 days, associated with slurring of speech and deviation of angle of mouth.
History of Present Illness: Patient was apparently well 2 days back when he suddenly developed weakness of left side of body. He had difficulty holding objects with left hand, inability to walk, deviation of mouth to the right side, and mild slurring of speech. No loss of consciousness. No seizures. No bladder/bowel involvement. Admitted to ER and diagnosed with right MCA territory ischemic stroke on CT/MRI brain.
Past History: H/o Hypertension (on Tab. Amlodipine 5 mg OD) | H/o Type 2 Diabetes Mellitus (on Tab. Metformin 500 mg BD) | No prior stroke or cardiac disease
Family History: Father had hypertension
Social History: Retired school teacher | Lives with family | Right-hand dominant | Lives in a ground floor house
O/E: (On Examination)
Higher Functions:
- Consciousness: Alert and oriented to time, place, and person
- Speech: Mild dysarthria present; comprehension intact
- Memory: Short-term memory mildly impaired
- Attention/Concentration: Mildly reduced
- Spatial neglect: Left-sided neglect suspected (inattention to left visual field)
- MMSE Score: 22/30
Cranial Nerves:
| Nerve | Finding |
|---|---|
| CN II | Vision intact bilaterally |
| CN III/IV/VI | Left homonymous hemianopia present; no ptosis or diplopia |
| CN V | Sensation intact bilaterally; jaw reflex normal |
| CN VII | Left lower facial weakness (UMN pattern) - nasolabial fold flattening on left; forehead sparing |
| CN VIII | Hearing intact |
| CN IX/X | Uvula deviates to right; mild dysphagia present |
| CN XI | Sternocleidomastoid and trapezius - full power bilaterally |
| CN XII | Tongue deviates to left on protrusion (UMN pattern) |
Plantar:
- Right: Flexor (normal)
- Left: Extensor (Babinski positive) - UMN sign
DTR (Deep Tendon Reflexes):
| Reflex | KJ (Knee Jerk) | AJ (Ankle Jerk) | BJ (Biceps Jerk) | TJ (Triceps Jerk) | BrJ (Brachioradialis Jerk) |
|---|---|---|---|---|---|
| Rt. | 2+ (Normal) | 2+ (Normal) | 2+ (Normal) | 2+ (Normal) | 2+ (Normal) |
| Lt. | 3+ (Hyperreflexia) | 3+ (Hyperreflexia) | 3+ (Hyperreflexia) | 3+ (Hyperreflexia) | 3+ (Hyperreflexia) |
(Grading: 0=absent, 1+=hyporeflexia, 2+=normal, 3+=hyperreflexia, 4+=clonus)
Note: Ankle clonus present on left side (3 beats)
Tone:
- Rt.: Normal (Normotonia)
- Lt.: Increased - Spasticity (velocity-dependent, clasp-knife pattern)
- UL: Flexor spasticity (elbow flexors, wrist flexors, finger flexors)
- LL: Extensor spasticity (quadriceps, plantar flexors) - classical UMN pattern
(Modified Ashworth Scale - Left UL: Grade 2 | Left LL: Grade 2)
VMC/Muscle Power (MRC Grading 0-5):
| Segment | Rt. UL | Rt. LL | Lt. UL | Lt. LL |
|---|---|---|---|---|
| Shoulder | 5/5 | - | 2/5 | - |
| Elbow | 5/5 | - | 2/5 | - |
| Wrist | 5/5 | - | 1/5 | - |
| Fingers | 5/5 | - | 1/5 | - |
| Hip | - | 5/5 | - | 2/5 |
| Knee | - | 5/5 | - | 2/5 |
| Ankle/Foot | - | 5/5 | - | 1/5 |
Summary:
- Rt. UL: 5/5 (Normal) | Rt. LL: 5/5 (Normal)
- Lt. UL: 1-2/5 (Severe weakness) | Lt. LL: 1-2/5 (Severe weakness)
Sensation:
- Superficial (Touch/Pain/Temperature): Decreased on left side (hemihypoesthesia)
- Deep (Proprioception/Vibration): Impaired proprioception in left hand and foot
- Cortical (2-point discrimination, stereognosis): Impaired left hand
- Right side: All sensations intact
T/O/D (Tone / Other / Deformity):
- Tone: Left-sided spasticity as above
- Other:
- Shoulder subluxation: Left shoulder - 1 finger-breadth subluxation palpable
- Edema: Mild pitting edema left hand
- Pain: Left shoulder pain (VAS 4/10) on passive movement
- Bladder: Urinary catheter in situ (neurogenic bladder)
- Deformity:
- Left wrist: Tendency toward flexion posture
- Left foot: Early equinovarus posture developing
- Hemiplegic posture: Left upper limb - shoulder adduction/internal rotation, elbow flexion, wrist/finger flexion; Left lower limb - hip adduction, knee extension, plantar flexion
Functional Assessment:
| Activity | Score / Status |
|---|---|
| Bed mobility (rolling) | Dependent |
| Supine to sit | Requires maximal assist (2-person) |
| Sitting balance (static) | Poor - cannot maintain >10 sec unsupported |
| Sitting balance (dynamic) | Unable |
| Sit to stand | Dependent |
| Standing balance | Unable independently |
| Gait | Non-ambulatory at present |
| Barthel Index | 15/100 (Total dependence) |
| Modified Rankin Scale | 4 (Moderately severe disability) |
| Berg Balance Scale | 4/56 |
PROGRESS SUMMARY
| Date | Time (Arriv/Dep) | Remarks | Signature |
|---|---|---|---|
| 12/07/26 | 09:00 / 09:45 | Initial PT assessment done. Started passive ROM exercises bilateral LL, passive ROM Lt. UL. Positioning taught to nursing staff. Chest physiotherapy initiated (breathing exercises). Goal-setting discussed with patient and family. | Physio |
| 13/07/26 | 09:00 / 09:50 | Active-assisted exercises Lt. UL/LL. Bed mobility training commenced. Sitting balance training (edge of bed). Shoulder subluxation strap applied. | Physio |
| 14/07/26 | 09:15 / 10:00 | Improved sitting balance - maintained 20 sec unsupported. Sit-to-stand training with maximal assist. Trunk stabilization exercises started. | Physio |
Physical Status (At the time of Discharge):
To be completed at time of discharge - anticipated goals:
- Sitting balance: Independent
- Standing with support: Independent
- Ambulation with tripod/AFO: Supervised
- Left UL power: Target 3/5 (functional assist)
- Barthel Index target: 50-60/100
- Plan: Continue outpatient PT 5x/week + home physiotherapy program + caregiver training
Clinical Notes for This Case
Diagnosis: Right MCA territory Ischemic Stroke with Left Hemiparesis (UMN type)
Key Features indicating UMN (Upper Motor Neuron) lesion post-stroke:
- Spasticity (not flaccidity) - characteristic of the subacute/chronic phase
- Hyperreflexia with clonus on the left side
- Extensor plantar (Babinski sign) on the left
- Lower facial weakness with forehead sparing (UMN pattern CN VII)
- Left homonymous hemianopia (optic radiation involvement)
- Hemihypoesthesia on affected side
Note: In the acute phase (first 24-48 hours), stroke commonly presents with flaccid hemiplegia and depressed reflexes (cerebral shock / diaschisis). The spasticity and hyperreflexia described above typically develop within days to weeks, which is consistent with a 2-day-old stroke just beginning its transition.
Physiotherapy Goals (Short term - 2 weeks):
- Prevent complications (contractures, DVT, pressure sores, shoulder pain)
- Improve sitting balance to independent
- Initiate gait training with aids
- Educate patient and family in home exercise program
Physiotherapy Goals (Long term - 3 months):
- Independent ambulation with or without assistive device
- Left UL functional use for ADLs
- Return to community ambulation
- Barthel Index > 60
Sources: Clinical findings are consistent with UMN stroke physiology described in Harrison's Principles of Internal Medicine 22E (UMN lesion characteristics: spasticity, hyperreflexia, Babinski sign) and Bradley and Daroff's Neurology in Clinical Practice (post-stroke rehabilitation patterns). Standard MRC grading, Modified Ashworth Scale, Barthel Index, and MRS criteria used as per established neurological physiotherapy practice.
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