I have had a patient who has been in hospital for a long period of time. At first the doctors have labeled her the mystery patient as they could not figure out what was wrong with her. She came in with malnutrition and abdominal pain. A serious of tests including blood, CT's and MRI's came back normal - they could not figure out what was wrong.
In the meantime i was working with the patient as she had pressure areas on her sacrum and heel, and she had de-conditioned and the simplest thing was hard for her e.g. pulling her pants down to go to the toilet - let alone getting to the toilet.
The patient was a 34 year old female, living in a HNZ flat with her flatmate (ex-partner).
She had no mental health history so know one had thought of perhaps she had an eating disorder. This was the doctors last resort - to get the psych team involved. Although it never really was a clear case she is now on an eating management plan and will be discharged once she gets to a certain weight.
2 weeks of assessment by the doctor had gone by, and im trying to think back of the time spent with this patient. Was there any indication that the patient may have been suffering from an eating disorder.
I remember thinking "how could someone get so sick without seeking medical treatment or intervention e.g. not getting out of bed and not making it to the toilet on time.
Maybe she was ashamed of herself, maybe her mood was affecting her drive to get better, maybe she was in denial that she even had a problem...
I remember her saying "i use to love food..but i cant eat it any more because it all tastes funny. Maybe this was an excuse. Maybe this was her reasoning for no longer enjoying food or no longer wanting to nourish herself
I remember her refusing PT input, maybe this was low drive affected by mood. in some ways the cues were there - but i never really analyzed them until afterwards
I guess i just expected that there was a "medical reason" for her illness because of her presenting complains e.g. pain and malnutrition
Just goes to show the process of assessment is a complex one and so very important - so many cues and hypothesis to think through and problem solve through
Tuesday, August 11, 2009
Sunday, July 5, 2009
7 weeks to go on medical
Oh time has flown - ive really been here for 6 months - and i feel like i have learnt alot - now to reflect on what the medical rotation has offered me and what i have developed skill in...
I feel i have developed better communication and confidence with talking with the medical team - especially communicating results of assessments for complex patients
I feel i have learnt so much about "cognition" but i wish to continue learning about this - it has become an interest of mine
I have learnt heaps about the medical processes including
a) involving other team members and referrals
b) handing over to rehab
c) assessing appropriateness for a period of rehab
d) organising home visits
e) liasing with family re: prior level of function
f) reasons for a cognitive assessment or when it is not appropriate
I next plan to assess my model against how i have fitted into this setting - and kind of a test it out
Jess
I feel i have developed better communication and confidence with talking with the medical team - especially communicating results of assessments for complex patients
I feel i have learnt so much about "cognition" but i wish to continue learning about this - it has become an interest of mine
I have learnt heaps about the medical processes including
a) involving other team members and referrals
b) handing over to rehab
c) assessing appropriateness for a period of rehab
d) organising home visits
e) liasing with family re: prior level of function
f) reasons for a cognitive assessment or when it is not appropriate
I next plan to assess my model against how i have fitted into this setting - and kind of a test it out
Jess
Wednesday, June 10, 2009
Case Review
I have an interesting case at the moment - well kind of complex
She is a 77 year old that as had numerous admissions to hospital over the last year. This admission was not directly linked to why she was referred to me. She was referred to me because she was presenting as very confused on the ward and repeating things that she had talked about already.
I went to see the patient and she presented rather "different". There was something about her that i couldn't pin point. She made a cup of milo indpendanly and safely on the ward but i chose to re-assess as i wasn't happy with the assessment data that i had gather.
I chose to do a standardised assessment - Hierarchic Dementia Scale. The results concluded that this patient had a severe short term memory impairment and mild-moderate attention/concentration, registration and long term memory issues.
From here i was concerned about the patients ability to manage in the community as she was home alone all day and was required to attend to personal cares, taking medications, and preparing lunch/breakfast throughout the day. So i decided to do a more complex functional task - preparing and light meal. From my observations she required assistance with searching and locating items (which shouldn't be problematic in a familiar environment) and remembering each instruction i had asked her to do e.g. "please can you make a pouched egg pn a piece of toast, present it on the table, and make a cup of tea to have with your meal...when you are finished can you please tidy up after you. The patient safely and Indep. prepared the meal but required prompting to tidy up. At times the patient became distracted and lost attention - pausing in the middle of the task - it was like she was thinking about what to do next - however she independently continued on with the task without prompting. I have no concerns about her ability to prepare simple meals and went back to talk to the team about my concerns about discharge
(1) - taking medications
(2) - managing finances
The team thought that a family meeting was appropriate so i went to contact the SW and family to organise this.
I got lots of useful information about the patient from contacting the family.
-The ST memory had been concerning them - she was been experiencing this for about 4-5 months however it has declined since her stroke about 6 weeks ago.
-They were concerned about her discharge location and the support that her partner could provide - as her partner had mentioned that he didn't know if he could cope with her ST memory decline - repetitiveness...
The goal of the family meeting is to
a) sort out discharge destination
b) sort out appropriate support for the patient - family or services
All will be relieved tomorrow - however this may take a bit of working with the family as it potentially could be a complex situation
Jess
She is a 77 year old that as had numerous admissions to hospital over the last year. This admission was not directly linked to why she was referred to me. She was referred to me because she was presenting as very confused on the ward and repeating things that she had talked about already.
I went to see the patient and she presented rather "different". There was something about her that i couldn't pin point. She made a cup of milo indpendanly and safely on the ward but i chose to re-assess as i wasn't happy with the assessment data that i had gather.
I chose to do a standardised assessment - Hierarchic Dementia Scale. The results concluded that this patient had a severe short term memory impairment and mild-moderate attention/concentration, registration and long term memory issues.
From here i was concerned about the patients ability to manage in the community as she was home alone all day and was required to attend to personal cares, taking medications, and preparing lunch/breakfast throughout the day. So i decided to do a more complex functional task - preparing and light meal. From my observations she required assistance with searching and locating items (which shouldn't be problematic in a familiar environment) and remembering each instruction i had asked her to do e.g. "please can you make a pouched egg pn a piece of toast, present it on the table, and make a cup of tea to have with your meal...when you are finished can you please tidy up after you. The patient safely and Indep. prepared the meal but required prompting to tidy up. At times the patient became distracted and lost attention - pausing in the middle of the task - it was like she was thinking about what to do next - however she independently continued on with the task without prompting. I have no concerns about her ability to prepare simple meals and went back to talk to the team about my concerns about discharge
(1) - taking medications
(2) - managing finances
The team thought that a family meeting was appropriate so i went to contact the SW and family to organise this.
I got lots of useful information about the patient from contacting the family.
-The ST memory had been concerning them - she was been experiencing this for about 4-5 months however it has declined since her stroke about 6 weeks ago.
-They were concerned about her discharge location and the support that her partner could provide - as her partner had mentioned that he didn't know if he could cope with her ST memory decline - repetitiveness...
The goal of the family meeting is to
a) sort out discharge destination
b) sort out appropriate support for the patient - family or services
All will be relieved tomorrow - however this may take a bit of working with the family as it potentially could be a complex situation
Jess
Friday, June 5, 2009
Sensory pathway - posterior/dorsal column
The posterior column-medial lemniscus pathway (dorsal column-medial lemniscus pathway) is the sensory pathway responsible for transmitting fine touch, vibration and conscious proprioceptive information from the body to the cerebral cortex.[1]
The name comes from the two structures that the sensation travels up: the posterior (or dorsal) columns of the spinal cord, and the medial lemniscus in the brainstem. Because the posterior columns are also called dorsal columns, the pathway is often called the dorsal column-medial lemniscus system, or DCML for short. (Also called posterior column-medial lemniscus or PCML pathway).
The name comes from the two structures that the sensation travels up: the posterior (or dorsal) columns of the spinal cord, and the medial lemniscus in the brainstem. Because the posterior columns are also called dorsal columns, the pathway is often called the dorsal column-medial lemniscus system, or DCML for short. (Also called posterior column-medial lemniscus or PCML pathway).
Observing some stroke patients and beginning input with stroke patients
I have had the opportunity to see a stroke patient today - she wasnt under the stroke team but her MRI came back with 2 R) Cerebellar infacts and CT results showed small ischaemic haemorrages.
Interestingly the patient had an inner ear infection about a month ago and her initial symptoms were suggestive of problems with inner ear - e.g. balance disturbance and dizziness...However she also had a headache and heart palipitations and ended up in hospital after collapsing (although not loosing conciousness).
I reviewed her notes and spent some time reviewing what had been happening for the patient. I had the opportunity to observe the registrar completing some sensory tests which was quite exciting.
She tested proprioception (asking the patient to close her eyes and describe the movement she was making with her metatarsel joint.
She tested vibration sense - with a metal fork that she banged and held on he joint asking the patient to identify when the vibration was present and when it stopped. I had the opportunity to experience what this sense felt like and the consultant was very helpful and also did a few other sensory tests on me
He did some sound and hearing tests with the vibration fork asking me to identify what sound of the fork was louder. He also put the end of the fork on my forehead and asking me to tell me what side was louder (was ment to be the same level of sound - which it was - so im normal)
The registrar also tested touch - with prick and dull pressure
The consultant tried to explain to me the senses they test for and it brought back some of the learning from teck about the spinal cord and the columns and which sense is associated with each - this interested me and i felt like looking this up on the net!
Next post will follow !!!!!!!!
As for my experience assessing this patient - her main issues were balance disturbance and fatigue
I completed an initial assessment wth the patient and identified any pre-dysfunction - good thing i did this becuase she had had a carpel tunnel repair to her effected side and this had already weakened her R hand strength.. She had no concerns about managing at home and the PT had assessed that she was safe for discharge with PT comm f/u.
I reviewed her function on the ward and set her home up for discharge, educated the patient on energy conservation etc.
After talking to my supervisor she took this a step further and we talked about fatigue diary as the patient still works and is keen to return to work as soon as possible. I plan to ring the patient next week and educate her on this
Fatigue diary - to rate the level of fatigue (am, late am, lunch, mid pm, late pm, bedtime) at various times and when doing activity. This aims to increase insight into fatigue levels during certain times of the day and during/after certain activities....then they can hopefully apply some energy conservation techniques to help control fatigue...
I also had the opportunity to observe the PT assessment - balance, gait, steps, nose finger (with increasing speed) and heel shin rub etc - it would be good if i could talk to the PT about what some of the more complex assessments were testing specifically - quite an interesting afternoon today!
Interestingly the patient had an inner ear infection about a month ago and her initial symptoms were suggestive of problems with inner ear - e.g. balance disturbance and dizziness...However she also had a headache and heart palipitations and ended up in hospital after collapsing (although not loosing conciousness).
I reviewed her notes and spent some time reviewing what had been happening for the patient. I had the opportunity to observe the registrar completing some sensory tests which was quite exciting.
She tested proprioception (asking the patient to close her eyes and describe the movement she was making with her metatarsel joint.
She tested vibration sense - with a metal fork that she banged and held on he joint asking the patient to identify when the vibration was present and when it stopped. I had the opportunity to experience what this sense felt like and the consultant was very helpful and also did a few other sensory tests on me
He did some sound and hearing tests with the vibration fork asking me to identify what sound of the fork was louder. He also put the end of the fork on my forehead and asking me to tell me what side was louder (was ment to be the same level of sound - which it was - so im normal)
The registrar also tested touch - with prick and dull pressure
The consultant tried to explain to me the senses they test for and it brought back some of the learning from teck about the spinal cord and the columns and which sense is associated with each - this interested me and i felt like looking this up on the net!
Next post will follow !!!!!!!!
As for my experience assessing this patient - her main issues were balance disturbance and fatigue
I completed an initial assessment wth the patient and identified any pre-dysfunction - good thing i did this becuase she had had a carpel tunnel repair to her effected side and this had already weakened her R hand strength.. She had no concerns about managing at home and the PT had assessed that she was safe for discharge with PT comm f/u.
I reviewed her function on the ward and set her home up for discharge, educated the patient on energy conservation etc.
After talking to my supervisor she took this a step further and we talked about fatigue diary as the patient still works and is keen to return to work as soon as possible. I plan to ring the patient next week and educate her on this
Fatigue diary - to rate the level of fatigue (am, late am, lunch, mid pm, late pm, bedtime) at various times and when doing activity. This aims to increase insight into fatigue levels during certain times of the day and during/after certain activities....then they can hopefully apply some energy conservation techniques to help control fatigue...
I also had the opportunity to observe the PT assessment - balance, gait, steps, nose finger (with increasing speed) and heel shin rub etc - it would be good if i could talk to the PT about what some of the more complex assessments were testing specifically - quite an interesting afternoon today!
Tuesday, May 12, 2009
PTA
This week i have had an interesting case - a 69 year old male who was admitted to hospital due to an unwitnessed fall resulting in facial and head fractures, a head injury and rib fractures. His GSC was 3/15 - identifying a serious head injury! 3 is also the total minimum score
He presents with the following symptoms of a head injury:
-sensitivity to light/sound
-agitation/restlessness/irritable
-poor attention/concentration
-poor orientation (person and time)
-lack of understanding of reasoning for being in hospital
-impaired short term memory
-saying bizarre things e.g. "the particular month is"
-extreme tiredness
I have commenced the PTA with this patient
Day 1 4/7
Day 2 5/12
Day 3...
From reading though my teck notes on PTA severity and if the patient stays in PTA for longer than 7 days this can be further classified as very severe head injury. Its sad to say but the longer the length of PTA the worser the outcomes...
After discussing my observations with my supervisor - we were able to determine that the patient was able to communicate basic "needs" e.g. thirst
It would be interesting to know if there has been any personality changes and get some information about pre-accident functioning so i can hand over to the rehab team
I have decided to do some reading about head injuries
Reference:
McWilliams, S. (1996). Head injury. In Turner, A., Foster, M., & JOhnson, S. E. (Eds.), Occupational therapy and physical dysfunction/. Principles, skills and practice (pp 463-469). New York: Churchill Livingstone.
He presents with the following symptoms of a head injury:
-sensitivity to light/sound
-agitation/restlessness/irritable
-poor attention/concentration
-poor orientation (person and time)
-lack of understanding of reasoning for being in hospital
-impaired short term memory
-saying bizarre things e.g. "the particular month is"
-extreme tiredness
I have commenced the PTA with this patient
Day 1 4/7
Day 2 5/12
Day 3...
From reading though my teck notes on PTA severity and if the patient stays in PTA for longer than 7 days this can be further classified as very severe head injury. Its sad to say but the longer the length of PTA the worser the outcomes...
After discussing my observations with my supervisor - we were able to determine that the patient was able to communicate basic "needs" e.g. thirst
It would be interesting to know if there has been any personality changes and get some information about pre-accident functioning so i can hand over to the rehab team
I have decided to do some reading about head injuries
Reference:
McWilliams, S. (1996). Head injury. In Turner, A., Foster, M., & JOhnson, S. E. (Eds.), Occupational therapy and physical dysfunction/. Principles, skills and practice (pp 463-469). New York: Churchill Livingstone.
Subscribe to:
Comments (Atom)