Clinical Applications Across the Lifespan

Transcription

1 Content & Format Case studies will be presented by groups of five people. Groups and clinical cases will be randomly assigned. Please carefully read the patient case study and respond to all questions as thoroughly as possible. Though it is important to be succinct in your writing, beware not to exclude any important details. Be sure to include a rationale for your answers where it is asked. You should work together as a group. Many of the questions have several possible correct answers. Sometimes a correct answer is not readily apparent. Use your best judgment, and openly discuss all ideas and options before deciding on a response. For every answer you give, you should always ask yourselves Why is this the best answer? You will submit your answers on a separate sheet of paper. Answers will be typed, double-spaced, with a minimum of 11 point type. Selected groups will present their patient to the class each week. A class discussion will follow. The presenting group can compare their ideas and answers with those of the class. HOMEWORK ASSIGNMENT: Entire class will be required to answer questions pertaining to the presentation. In order receive full credit for the homework assignment, questions will need to be answered accurately, thoroughly, and provide a rationale for the answer. Grading Each case study is graded on a 150 point scale. Format 25 All format criteria are followed according to established guidelines 20 Most format criteria are followed according to established guidelines 15 Some format criteria are followed according to established guidelines 10 Few format criteria are followed according to established guidelines 5 Little to no format criteria are followed according to established guidelines -1-

2 Focus and Purpose of Narrative 25 Well developed and clear, relevant statements that engage the reader 20 Well developed ideas in narrative 15 Mostly good ideas, but expression is weak 10 Mostly simplistic, unfocused ideas. Little or no sense of overall purpose 5 Ideas are extremely simplistic, showing signs of confusion and lack of purpose Writing Mechanics 25 Virtually free of punctuation, grammatical and spelling errors. Formatting is appropriate 20 Occasional punctuation, grammatical, spelling, and/or formatting errors 15 Contains a moderate amount of punctuation, grammatical, spelling, and/or formatting errors 10 Contains several punctuation, grammatical, spelling, and/or formatting errors 5 Contains serious errors in punctuation, grammar, spelling, and/or formatting Response to Questions 25 Answers all questions accurately and thoroughly. Provides a rationale for answers, when requested 20 Answers all questions thoroughly, though accuracy and/or rationale may contain some errors 15 Answers all questions. Responses are not thorough. Contains a moderate amount of errors or misjudgments 10 Does not answer all questions and is not thorough or accurate. 5 Minimal effort in responses. Contains significant errors or misjudgments -2-

3 Homework Assignment - Summary of Presentation 50 Answers questions accurately and thoroughly. Provides a rationale for answers, when requested 40 Answers questions thoroughly, though accuracy and/or rationale may contain some errors 20 Answers questions. Responses are not thorough. Contains a moderate amount of errors or misjudgments 30 Does not answer all questions and is not thorough or accurate 10 Minimal effort in responses. Contains significant errors or misjudgments Total Points: /150-3-

4 Patient Scenario Patient is a 72- year old male who was diagnosed with PD 12 years ago. He has recently experienced increasing severity of symptoms and is referred to outpatient physical therapy and a HEP. Prior Medical History Patient s prior medical history received from attending/referring physician is unremarkable except for hypertension, which is being treated with Metoprolol. Physician remarks include patient is currently diagnosed at Stage III on the Hoehn and Yahr Classification of Disability. Subjective He resides in an independent living facility with his wife. Patient states this environment provides a wide spectrum of social interaction and cognitive challenges as well as good access to health care. Patient states he is aware of the effects of his illness. Patient cites unsteadiness when walking, during transfers, and dressing. He also reports increased falls in the past several weeks. He is afraid he might sustain severe injury following a serious fall at home. He also states that his wife provides assistance for bed mobility and transfers. Patient states his current medications are Sinemet and Mirapex. He reports he experiences freezing episodes when his medications wear off. As a result, he and his wife carefully plan outings around peak medication times. Objective ROM: PROM is WNL to all four extremities MMT: BUE: WNL BLE 3/5 throughout all ranges, except bilateral ankle dorsiflexors which is 2/5 Vital Signs seated: RHR = 64bpm, radial pulse site BP = 125/80 O2 saturation = 97% on room air -4-

5 Assessment Stooped posture, rounded shoulders, thoracic kyphosis Motor: Hesitation on initiation of movement Ambulates without an A.D. and demonstrates a festinating gait Demonstrates decreased arm swing and decreased reciprocal trunk movements Presents with pill-rolling tremor at rest MIN A x 1 person with bed mobility Requires MIN A x 1 person for sit/supine, supine/sit transfer Requires MIN A x 1 person for sit/stand, stand/sit transfer Static/Dynamic Sitting Balance: Good Static/Dynamic Standing Balance: Fair Tone: Demonstrates trunk rigidity Tinetti Balance Test: 17/28 Functional Reach Test: 6 inches Berg Balance Test: 38/56 Demonstrates slow reactions to loss of balance Mental status is Alert and Oriented x 3 Speech: Normal Sensation: Slightly decreased proprioception in BLE Plan 1. Gait training 2. Therapeutic exercise 3. Balance activities 4. Transfer activities 5. Educate patient and spouse on safety awareness 6. Educate patient and spouse on self-management skills (good posture, daily walking, benefits of sustained activity) 7. Patient will be seen for outpatient services, 3x week for 4 weeks STG: Increase MMT for bilateral ankle dorsiflexion to 3/5 STG: Increase BLE MMT to 3+/5 throughout all ranges STG: Increase static/dynamic standing balance to Fair+ STG: Increase arm swing and reciprocal trunk movements during gait and reduce festinating gait STG: Decrease trunk rigidity STG: Increase all bed mobility skills to SBA STG: Increase all functional transfers to SBA STG: Supervised with HEP STG: Educate patient and spouse on self-management skills -5-

6 STG: Increase Functional Reach Test score by 1 inch STG: Berg Balance Test score to 44/56 LTG: Increase BLE MMT to 4/5 LTG: Increase MMT for bilateral ankle dorsiflexion to 4/5 LTG: Increase arm swing and reciprocal trunk movements to decrease festinating gait LTG: Increase Functional Reach Test by 2 inches LTG: Berg Balance Test score to 50/56 LTG: Will be IND for all functional transfers and bed mobility skills LTG: IND with HEP Precautions Fall risk Patient fatigues easily Please answer the following questions regarding this patient: 1. Formulate two treatment interventions you would use with this patient on his first day of physical therapy. Please provide a detailed description. 2. Over the next week, what areas would you focus on to achieve STGs? What activities would you choose for this patient over the next week of therapy? Provide a detailed rationale for your answer. 3. Design a HEP for this patient. You have been the primary PTA treating this patient. Towards the end of Week 2, the patient presents at the outpatient facility with a decline in gait and transfer abilities. His wife states the patient has been overdoing it a bit as they have family visiting, which has resulted in frequent bouts of moderate fatigue. Patient and patient s wife report these bouts of fatigue occur as patient s medication begins to wear off. 4. A. At this point, what would you discuss with the patient and the patient s spouse. Would you report these findings to the supervising therapist? What would you report and recommend to the supervising therapist? Please provide a detailed explanation for your answer. B. What activities would you focus on during this therapy session? Provide a rationale for your answer. The patient is approaching the end of his therapy sessions in the outpatient clinic. His insurance company will not reimburse for further outpatient therapy at this time. The insurance company will not approve home health. He has achieved all of his STGs. He has achieved the following LTGs: -6-

7 BLE MMT 4/5 (expect ankle dorsiflexion) Increased Functional Reach Test by 2 inches Berg Balance Test score 50/56 He is IND for bed mobility skills MMT for bilateral ankle dorsiflexion remains 3/5 He continues to present with decreased arm swing and reciprocal trunk movement during gait He continues to present with a festinating gait unless cued to correct self Dynamic/Static standing balance is Fair+ He is supervised for all functional transfers. He is supervised with the HEP 5. Based on this information, is this a safe discharge from outpatient therapy services? Why or why not? What recommendations would you provide to the supervising therapist? Provide a rationale for your answer. You have discussed this case with the supervising therapist who asks you to complete a home assessment. 6. Use the information previously provided by Dr. Mills to complete this home assessment. Keep in mind the patient and his spouse live in an independent living facility. During the home assessment, you discover the patient has access to a fitness facility that is supervised. The facility has access to weight-training and cardiovascular equipment. They also offer group fitness exercise classes for seniors. 7. What recommendations would you make to the supervising therapist, patient and patient s spouse based on the completed home assessment? Provide a detailed explanation of your answer. 8. Would you recommend the patient utilize the fitness facility at his independent living facility? Why or why not? Would you discuss this recommendation with your supervising therapist? The patient s primary physician? Provide a rationale for your answer. 9. What safety awareness and self management skills would you educate the patient and his spouse? 10. What community support groups are available for the patient and his family? -7-