stroke case study

Social work Report: Patient is a 58-year old female, who lives alone with her husband in" rel="nofollow">in their home in" rel="nofollow">in Trout Creek. Her husband is 72 years old, and has been on disability for 12 years due to advanced COPD. He is on home oxygen, and fatigues easily. Patient provides assistance to her husband with ADL’s, and completes all necessary housework. She has a son, who is divorced and lives in" rel="nofollow">in Plain" rel="nofollow">ins. She also has a daughter in" rel="nofollow">in Florida who is estranged from the family. She has one siblin" rel="nofollow">ing, a brother, who is termin" rel="nofollow">inally ill with lung cancer. Both her parents and in" rel="nofollow">in-laws are deceased. Patient is self-employed as a seamstress. She works in" rel="nofollow">in a small shop located on the home property. She has no medical in" rel="nofollow">insurance, and is not yet eligible for Medicare. Regardin" rel="nofollow">ing assets, she and her husband own their own home. Her husband receives a pension and Social Security totalin" rel="nofollow">ing $2200 per month. He has Medicare for his health costs, but pays approximately $250 per month out-of-pocket for prescription medications. Patient was contributin" rel="nofollow">ing approximately $1000 per month of in" rel="nofollow">income. She and her husband have approximately $2000 in" rel="nofollow">in savin" rel="nofollow">ings at this time. The patient and her husband are adamant about not leavin" rel="nofollow">ing their home in" rel="nofollow">in Trout Creek, in" rel="nofollow">insistin" rel="nofollow">ing that this home is where they plan to spend the rest of their lives. Their current assets will more than likely prevent patient from receivin" rel="nofollow">ing services through Medicaid. Patient has been denied in" rel="nofollow">inpatient rehabilitation services. She and her husband are eager to have her return home. Home health services are available from Plain" rel="nofollow">ins, however, the services will need to be paid out-of-pocket. Mr. Keene may be able to receive some home assistance through Medicare, but will need to be evaluated for need. After discussion with the family, their desire is to have the patient return home and receive "a few therapy sessions" to rein" rel="nofollow">inforce what has been started in" rel="nofollow">in the hospital. The son states he is willin" rel="nofollow">ing to help out a few days a week at home, but he works the swin" rel="nofollow">ing shift and is unable to stay for more than a couple of hours at a time. The family is in" rel="nofollow">interested in" rel="nofollow">in obtain" rel="nofollow">inin" rel="nofollow">ing personal care assistance personnel. I remin" rel="nofollow">inded the family that such assistance would have to be hired privately. The family is very concerned about the mountin" rel="nofollow">ing costs of hospitalization, and are requestin" rel="nofollow">ing a discharge as soon as possible. Recommedations: 1. Schedule discharge plannin" rel="nofollow">ing meetin" rel="nofollow">ing with team. 2. Obtain" rel="nofollow">in Home Health consult. 3. Review options with family after in" rel="nofollow">input from team. Occupational therapy report: This 58-year old female was admitted with a right middle cerebral artery stroke on July 12, 2007. At this time, she is alert and oriented to person and place only. She is able to follow simple commands. Speech is slurred, but understandable. She has a left visual field cut. Sensation is grossly in" rel="nofollow">intact, though extin" rel="nofollow">inction noted on the left. Left arm is weaker than the right at 4/5, with hand and wrist strength most affected. She has mild ataxia with the left hand. She is right-handed. Patient is able to adequately wash face and comb hair with min" rel="nofollow">inimal cues. However, oral hygiene is impaired, with patient neglectin" rel="nofollow">ing left side of her mouth and poor control with oral rin" rel="nofollow">insin" rel="nofollow">ing. With dressin" rel="nofollow">ing, patient needs moderate assistance with pullin" rel="nofollow">ing on underclothes and socks. She is unable to button her bathrobe. General impulsivity is noted with activities, and she requires many clues to stop, and proceed through tasks sequentially. At this time, I am unable to obtain" rel="nofollow">in in" rel="nofollow">information about the home settin" rel="nofollow">ing due to possible fatigue/ confusion from the patient. Family members not present at this time. Recommendations: 4. Left hand strengthenin" rel="nofollow">ing and coordin" rel="nofollow">ination exercises. 5. Pacin" rel="nofollow">ing of activities and in" rel="nofollow">instruction due to impulsivity. 6. Consult with speech regardin" rel="nofollow">ing oral safety. 7. Obtain" rel="nofollow">in assistive dressin" rel="nofollow">ing equipment and provide train" rel="nofollow">inin" rel="nofollow">ing. 8. Evaluate toiletin" rel="nofollow">ing activities after consultin" rel="nofollow">ing with physical therapy regardin" rel="nofollow">ing capabilities/ equipment needs. 9. Obtain" rel="nofollow">in in" rel="nofollow">information regardin" rel="nofollow">ing the home environment from family. 10. Occupational therapy BID for now. Goals: 1. Able to complete toiletin" rel="nofollow">ing and basic hygiene activities with min" rel="nofollow">inimal supervision (<25%). 2. Completion of home environment evaluation if not transferred to rehabiliation. 3. Independence with use of dressin" rel="nofollow">ing equipment. 4. Improved coordin" rel="nofollow">ination with left hand so that ataxia does not impair safety or completion of ADL’s. Physical therapy report: A. History – The followin" rel="nofollow">ing history was obtain" rel="nofollow">ined from the medical record or the patient’s husband: This 58-year old female was admitted with a right middle cerebral artery stroke on July 12, 2003. At that time she presented with aphasia and in" rel="nofollow">inability to move her LUE and LLE. Past Medical History – Unremarkable. Patient takes no prescription medications. Social History – The patient smoked 2 packs per day for 15 years, but has not smoked sin" rel="nofollow">ince 1975. She is a social drin" rel="nofollow">inker and drin" rel="nofollow">inks ½ pot of coffee daily. She lives with her husband and is self-employed as a seamstress. Her husband has COPD with medical disability and has limited ability to physically assist his wife. They have 2 children, one in" rel="nofollow">in-state, one out-of-state. Home – The patient and her husband live in" rel="nofollow">in a 2 story home with the bedroom and primary bathroom on the second floor. There are 3 steps without a railin" rel="nofollow">ing at the entrance of the home. The home has a gravel driveway with 15 feet from the garage to the hourse door. B. Systems Review Cardiovascular/Pulmonary – BP variable, today 155/82; HR 74 regular, RR 18. Medical telemetry in" rel="nofollow">indicates rare PVC’s. O2 saturation 92% at rest with 3L O2. O2 sat decreases to 88% with activity. O2 saturation also decreases with nighttime apneic episodes. Bilateral base crackles audible in" rel="nofollow">in both lungs. Integumentary – in" rel="nofollow">intact, no pressure ulcers noted, slight swellin" rel="nofollow">ing bilaterally in" rel="nofollow">in both LE’s. No cancerous or precancerous appearin" rel="nofollow">ing lesions noted on skin" rel="nofollow">in. Musculoskeletal & Neuromuscular – See specific tests & measures below. Communication – Oriented to person & place. Speech slurred, able to follow 1 step commands C. Tests and Measures Sensorimotor Function – RUE, RLE, R trunk ROM and strength WNL. LUE: L shoulder ROM limited in" rel="nofollow">in elevation to about 110 degrees due to pain" rel="nofollow">in. Voluntary motion present, able to take slight resistance, (3+/5). L elbow has full ROM and voluntary motion is present, able to take some resistance (4/5 flexion, 3-/5 extension), in" rel="nofollow">increased tone in" rel="nofollow">in elbow flexors. L forearm & hand has slight voluntary motion, no resistance (2/5). LLE: voluntary motion present in" rel="nofollow">in L hip/knee/ankle. Can take slight resistance in" rel="nofollow">in L hip and Knee (3+/5). Ankle dorsiflexion 3/5, in" rel="nofollow">increased tone noted in" rel="nofollow">in ankle plantar flexors. L trunk: mild ataxia noted Sensation on L grossly in" rel="nofollow">intact to touch, tends to ignore L side. L visual field deficit past 30 degrees. Functional Abilities – Bed mobility: Good. Able to roll to both sides, scoot up and down in" rel="nofollow">in bed. Transfers: Supin" rel="nofollow">ine to sit – CGA with verbal cuin" rel="nofollow">ing required for safety and limb position Sit to Stand – Mod assist X 1, verbal cuin" rel="nofollow">ing required Mobility: min" rel="nofollow">inimal w/c skills at this time, ambulation 10 ft, front wheeled walker, min" rel="nofollow">in assist X 1, poor balance, verbal cuein" rel="nofollow">ing required, tends to adduct LLE, able to clear L foot with cuein" rel="nofollow">ing, stairs mod assist X 1 with bilateral rails and verbal cuein" rel="nofollow">ing. Balance: Sittin" rel="nofollow">ing balance is fair, able to sit without support about 30 seconds, tends to fall to L. Standin" rel="nofollow">ing balance is fair, able to stand about 1 min" rel="nofollow">inute, CGA required for balance. Requires frequent verbal cuin" rel="nofollow">ing for safety and balance. II. Problem List 11. Reduced ability to perform supin" rel="nofollow">ine to sit, sittin" rel="nofollow">ing balance, w/c mobility, sit to stand, standin" rel="nofollow">ing, and ambulation. Min" rel="nofollow">inimal to moderate assistance X 1. 12. Balance fair – min" rel="nofollow">inimal assist to CGA 13. Increased risk of fallin" rel="nofollow">ing due to in" rel="nofollow">inattention to L side and limited balance. 14. Safety concerns due to frequently needed cuin" rel="nofollow">ing, attemptin" rel="nofollow">ing tasks before direction, and reduced awareness of L side. 15. O2 sat drops below 90% with activity and no exogenous O2. III. Physical Therapy Diagnosis Practice Pattern – Neuromuscular: Impaired Sensorimotor Function associated with Non-progressive Disorder of the CNS Acquired in" rel="nofollow">in Adulthood. ICD-9 Medical Diagnosis Code 434 Occlusion of Cerebral Arteries IV. Prognosis Patient Goal: Return home with husband and return to work. Long Term Goals: Rehabilitation Potential Good. Followin" rel="nofollow">ing home health physical therapy the patient will be able to: 5. Functional abilities: sit unsupported 5 min" rel="nofollow">inutes; community mobility in" rel="nofollow">in w/c with supervision; transfer, ambulate household distances, and up/down stairs with assistive device with verbal cuin" rel="nofollow">ing. 6. Monitor LUE and LLE for position and follow 2 step commands without verbal cuein" rel="nofollow">ing. 7. Wait for supervision before performin" rel="nofollow">ing motor tasks. Short Term Goals: Upon discharge from the hospital (2-3 days), the patient will be able to: 1. Require only verbal cuin" rel="nofollow">ing for supin" rel="nofollow">ine to sit. 2. Sit unsupported for 2 min" rel="nofollow">inutes in" rel="nofollow">independently 3. Perform Sit to Stand with min" rel="nofollow">inimal assist 4. Ambulate with front wheeled walker 25 feet, CGA for balance 5. Climb 3 stairs without railin" rel="nofollow">ing, min" rel="nofollow">inimal assist 6. Follow 2 step commands 70% of the time 7. Wait for directions & supervision 70% of the time 8. 9. V. Interventions 1. Patient will receive PT services BID until hospital discharge. PT will participate in" rel="nofollow">in all team and discharge plannin" rel="nofollow">ing meetin" rel="nofollow">ings. Discharge evaluation and treatment plan will be transmitted to home health agency. 2. Patient and husband will be in" rel="nofollow">instructed on transfer, w/c skills, ambulation, and stair climbin" rel="nofollow">ing strategies to in" rel="nofollow">include falls risk reduction and verbal cuin" rel="nofollow">ing. 3. Daily BID therapy sessions will in" rel="nofollow">include: 1. Sensory awareness exercises to in" rel="nofollow">increase monitorin" rel="nofollow">ing of LUE and LLE. 2. Therapeutic exercise to in" rel="nofollow">increase voluntary control of LUE, LLE, and L trunk. 3. Functional train" rel="nofollow">inin" rel="nofollow">ing for supin" rel="nofollow">ine to sit, sit to stand, sittin" rel="nofollow">ing & standin" rel="nofollow">ing balance, w/c skills, ambulation, and stairs. Based upon the in" rel="nofollow">information in" rel="nofollow">in the social work and therapy consultations, are the family’s discharge expectations realistic? Why or why not? What is your recommendation for this family? Describe your thought processes as you dealt with this question. Was this decision difficult? If so, why?