Sunday, September 6, 2009

Interesting case

I have a patient at the moment who presented to hospital with confusion +++ and a severe UTI. Over the last few months he has been declining in cognition and has become more regularly confused and disorientated. His UTI definitely exacabated his confusion and he became more aggressive also.
When i first met the man he was disorientated to time, place and person and was being aggressive towards the nursing staff. At this time he was also having difficulties answering questions but it was hard to determine whether this was difficulties with attention, comprehension or expression.
It is now 4 days later, and he is more orientated to time, place and person. HOwever he is still having difficulties answering questions
e.g. what city are we in - he verbally said the wrong answer but when asked to write it down he got it correct
This tends to suggest he was having difficulty expressing..however when asked to say his date of birth he got the numbers mixed up e.g. 24 Month 1922 instead of 22 Month 1924. When asked to right it down he still couldn't figure it out, and there were some cross outs and several attempts made.

His wife reports he has had difficultly over the last month expressing what he wants e.g. he asked for an ice berg when he wanted an eskimo pie ice cream. When his wife tries to figure out what he means and gets it wrong or cannot guess he gets very angry and frustrated.

I have decided to do an HDS cognitive screen as his memory, registration and ?attention are concerning. I would like to do a broader assessment before i took into his difficulty expressing what he wants. It appears he knows what he wants to say but is having difficulty expressing it - like a verbal expressive aphasia

From researching this i have found some interesting information ...

Expressive aphasia, known as Broca's aphasia in clinical neuropsychology and agrammatic aphasia in cognitive neuropsychology, is an aphasia caused by damage to or developmental issues in anterior regions of the brain, including (but not limited to) the left posterior inferior frontal gyrus known as Broca's area
Middle cerebral arteries supplies this area
Aphasia's usual result from brain lesion

Anyway this all needs further investigation and definitely follow up in the community perhaps with the community rehab team
I know the medical team were planning a CT scan - be good to follow this up also


Wednesday, September 2, 2009

Advocating for rehab

A patient i had been working with was recently diagnosed with Motor Neuron Disease (MND).
The patient had declined in mobility and therefore occupational performance since admission and from a medical perspective rehab was not appropriate.

HOWEVER - I thought different!
This patient was a 73 year old male who lives with his wife (who has started doing everything for the patient).
He has had some input from the Community Rehab team - and so the medical team thought it would be appropriate for the patient to go home with follow up. However he had declined since admission

Pre-admission he was walking and falling
Now he was only managing transfers - and it was deemed unlikely that he would gain much mroe ability to walk.

SO... As an advocate in MDT meeting i disucssed to the medical team and others that Inpatient rehab would be very beneficial to enable the patient to adjust to a change in occupational performance and learn to compensate for his reduced mobility. The PT supported me and the medical team (may not have understood) but at least trusted that we were making an appropriate recommendation.

SO...the patient was accepted for an inpatient rehab stay and i have set clear OT goals that the patient wants to achieve when he is in rehab.

Good outcome of advocacy and communication!

Case Review

I was referred a patient who lives with his family and his a well respected Maori Elder in the community. He was presenting as what nursing staff described as "innappropriate" "confused" and "vague".
I went to see this gentleman and we got chatting about his roles and values at home. He looks after his grandchildren with his wife and values this alot.
I explained my role and the reason i had received a referral. He admitted that his brain wasnt as fast as it use to be and his thinking was alot slower. I began asking some questions to screen his cognition. When i asked him a question he would not respond with an appropriate response - change the subject and talk about his medical condition.
So was this hearing?, not wanting to answer my question? didnt know the answer? Or more likely cultural????????????
As i went on i wondered if he was feeling quite intimidated by me. I remember thinking back about the Maori Culture and i thought it must of been hard for him to have a "young" "white" "girl" ask him questions and "testing him".
I reflected on this case and talked about it with an OT colleauge. This was probebly the case as he was recognised as a Maori Elder. It all made sense as i ended the session when he said he felt interigated as he didnt know what the questions were about and why i was asking them (even though i had explained)
I did have concerns however about his cogntiion and i didnt want to leave my assessment at that as i had alot of information and no idea what to i contacted the Maori Liason unit and asked if they would support me by visiting him with me. The plan was to assess him preparing a meal however it ended up that the pysch geri team leader arrived to see the patient at the same time so we all sat around and chatted together.
The patient also identified that he would prefer to be assessed in his own environemnt which became the plan with f/u from pysch geri OT.

All in all a good learning experience in respecting the Maori culture and not pushing the boundaries. Also a good use of the Maori Liason unit as they new the patient well though the community and were able to explain what he is usually like.