Sunday, February 14, 2010

Case review

Case Review
Reason for referral:
Leg gave way, due to pain in the side of his waist - lost balance - fall - # R) ankle - ORIF – TWB
Supplementary fall post injury when showering before presenting to ED
Person information:
70 year old male
Social information:
Lives alone Supportive Daughter in the area No formal supports
Medical/Therapy hx:
Tumour removed 20 years ago from cervical spine- resulting in nerve damage
Graduated decline in sensory loss, and resulting gait pattern disturbances
• Sensory assessment: Wears glasses; Profoundly deaf
• Specific sensory loss in R) leg (from hip down:
 -no proprioception
 -impaired temperature sensation (hot/cold)
 -impaired pin prick sensation Specific motor loss in R) leg -decreased power & tonal changes
• Initial assessment
• Discussion with pt’s Daughter
Current Occupational Performance:
Independent bed mobility, lying to sitting and sit to stand from bed
UTT with supervision (due to gait disturbance and unsafe TWB mobility status
Independent grooming and self catheterisation
Assistance with lower limb wash/dry/dress
Independent with upper body/limb wash/dry/dress
Profound hearing loss possibly associated with not comprehending advice/instruction
Mild short term memory loss
High falls risk due to multiple factors (propriception not intact; new gait pattern; TWB mobility status; poor balance on L foot and decreased ROM on L) ankle; fatigue; a little impulsive).
Presenting problems:
Daughter concerned about memory loss
PT concerned about safety re: mobility and gait
OT concerned about overall ability to manage ADL’s with reduced sensation in R) leg and recommending a full review of occupations (and retraining to compensate for this.
OT and PT concerned about high falls history
OT concerned about hearing loss and ability to engage in communication in the community e.g. whether this has been the issue – instead of short term memory loss
Summary of OT input:
I had reviewed this patients notes and noticed that he had some major deficits, a very high falls hx, and his Daughter was concerned about his cognitive functioning in particular his memory. I happened to be around when the Psych Geri Dr was doing his round, and observed the medical team with the ACNM for an opportunity to gain some background information. This was very beneficial as I was introduced to some of the patients "physical" difficulties and was able to get a good social hx as well as a good account of his pre-admission occupational performance.
Following this, I met with the patient and his Daughter, introduced myself and explained my role.
I gained consent to complete an OT initial assessment, and found that I already had the answers to a lot of the questions, which sped up the process but also gave me the opportunity to look further into things. E.g. The patient had told the doctor of his normal walking pattern which I had noted, then I was able to ask him about his falls hx, and how this affected his independence with his daily tasks...he told me some concerning stories - like how he fell in the shower and got stuck. So I had determined that this patients pre-admission functioning was not particularly safe, and that sensory disturbances were a very impacting matter.

Process of assessing appropriateness for a period of OPRS:
After his operation I discussed this case with the ACNM and another Psych Geri Dr, re: what their thoughts were as for discharge planning. They said they would go by the PT/OT opinions, so I booked in a joint OT/PT session that afternoon with the PT, and we saw him together (It was really for a mobility and transfer session - so that I could talk with the PT afterwards re: ?appropriateness of OPRS. At this stage I talked with the patients nurse re: his hearing and she went ahead and booked him an audiology appointment.
So after the session the PT had made up her mind that OPRS was appropriate for the following reasons: for safety with mobilising and correct/safe technique - as he was a little impulsive.
I agreed, but for more OT specific reasons including:
a) Comprehensive assessment of ADL's to determine occupations that are unsafe due to decreased sensation etc.
b) Re-training to improved safety with ADL's to compensate for his decreased proprioception/sensation (SOME OF WHICH WILL BE MORE APPROPRIATE ONCE HE IS OUT OF HIS CAST)
c) Screening of cognition

OT Goals:
In 4 weeks, pt to be safe and independent with performing daily self care tasks e.g. showering, dressing by retraining techniques and utilising compensatory equipment for paralysis/sensory loss in R) leg, in order to return home and be safe living in the community.
In 4 weeks, pt to have his hearing assessed and cognitive functioning reviewed to rule out any significant impairment that may affect his safety to live independently.
In 4 weeks, pt to be safe preparing a meal by retraining techniques and utilising compensatory equipment for sensory loss in R) leg, in order to return home and be safe living in the community.
In 8 weeks, (once out of plaster) pt to be reviewed by OPRS community team to re-assess pt’s occupational performance once FWB, in order to ensure safe and independent occupational performance whilst compensating for L) leg paralysis/sensation loss.

Transfer to OPRS inpatient team

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