stroke case study
Social work Report:
Patient is a 58-year old female, who lives alone with her husband in their home 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 Plains. She also has a daughter in Florida who is estranged from the family. She has one sibling, a brother, who is terminally ill with lung cancer. Both her parents and in-laws are deceased. Patient is self-employed as a seamstress. She works in a small shop located on the home property. She has no medical insurance, and is not yet eligible for Medicare.
Regarding assets, she and her husband own their own home. Her husband receives a pension and Social Security totaling $2200 per month. He has Medicare for his health costs, but pays approximately $250 per month out-of-pocket for prescription medications. Patient was contributing approximately $1000 per month of income. She and her husband have approximately $2000 in savings at this time. The patient and her husband are adamant about not leaving their home in Trout Creek, insisting that this home is where they plan to spend the rest of their lives. Their current assets will more than likely prevent patient from receiving services through Medicaid.
Patient has been denied inpatient rehabilitation services. She and her husband are eager to have her return home. Home health services are available from Plains, 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 reinforce what has been started in the hospital. The son states he is willing to help out a few days a week at home, but he works the swing shift and is unable to stay for more than a couple of hours at a time. The family is interested in obtaining personal care assistance personnel. I reminded the family that such assistance would have to be hired privately.
The family is very concerned about the mounting costs of hospitalization, and are requesting a discharge as soon as possible.
1. Schedule discharge planning meeting with team.
2. Obtain Home Health consult.
3. Review options with family after 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 intact, though extinction 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 minimal cues. However, oral hygiene is impaired, with patient neglecting left side of her mouth and poor control with oral rinsing. With dressing, patient needs moderate assistance with pulling 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 information about the home setting due to possible fatigue/ confusion from the patient. Family members not present at this time.
4. Left hand strengthening and coordination exercises.
5. Pacing of activities and instruction due to impulsivity.
6. Consult with speech regarding oral safety.
7. Obtain assistive dressing equipment and provide training.
8. Evaluate toileting activities after consulting with physical therapy regarding capabilities/ equipment needs.
9. Obtain information regarding the home environment from family.
10. Occupational therapy BID for now.
1. Able to complete toileting and basic hygiene activities with minimal supervision (<25%). 2. Completion of home environment evaluation if not transferred to rehabiliation. 3. Independence with use of dressing equipment. 4. Improved coordination with left hand so that ataxia does not impair safety or completion of ADL’s. Physical therapy report: A. History – The following history was obtained 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 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 since 1975. She is a social drinker and drinks 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-state, one out-of-state. Home – The patient and her husband live in a 2 story home with the bedroom and primary bathroom on the second floor. There are 3 steps without a railing 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 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 both lungs. Integumentary – intact, no pressure ulcers noted, slight swelling bilaterally in both LE’s. No cancerous or precancerous appearing lesions noted on skin. 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 elevation to about 110 degrees due to pain. 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), increased tone in elbow flexors. L forearm & hand has slight voluntary motion, no resistance (2/5). LLE: voluntary motion present in L hip/knee/ankle. Can take slight resistance in L hip and Knee (3+/5). Ankle dorsiflexion 3/5, increased tone noted in ankle plantar flexors. L trunk: mild ataxia noted Sensation on L grossly 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 bed. Transfers: Supine to sit – CGA with verbal cuing required for safety and limb position Sit to Stand – Mod assist X 1, verbal cuing required Mobility: minimal w/c skills at this time, ambulation 10 ft, front wheeled walker, min assist X 1, poor balance, verbal cueing required, tends to adduct LLE, able to clear L foot with cueing, stairs mod assist X 1 with bilateral rails and verbal cueing. Balance: Sitting balance is fair, able to sit without support about 30 seconds, tends to fall to L. Standing balance is fair, able to stand about 1 minute, CGA required for balance. Requires frequent verbal cuing for safety and balance. II. Problem List 11. Reduced ability to perform supine to sit, sitting balance, w/c mobility, sit to stand, standing, and ambulation. Minimal to moderate assistance X 1. 12. Balance fair – minimal assist to CGA 13. Increased risk of falling due to inattention to L side and limited balance. 14. Safety concerns due to frequently needed cuing, attempting 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 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. Following home health physical therapy the patient will be able to: 5. Functional abilities: sit unsupported 5 minutes; community mobility in w/c with supervision; transfer, ambulate household distances, and up/down stairs with assistive device with verbal cuing. 6. Monitor LUE and LLE for position and follow 2 step commands without verbal cueing. 7. Wait for supervision before performing motor tasks. Short Term Goals: Upon discharge from the hospital (2-3 days), the patient will be able to: 1. Require only verbal cuing for supine to sit. 2. Sit unsupported for 2 minutes independently 3. Perform Sit to Stand with minimal assist 4. Ambulate with front wheeled walker 25 feet, CGA for balance 5. Climb 3 stairs without railing, minimal 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 all team and discharge planning meetings. Discharge evaluation and treatment plan will be transmitted to home health agency. 2. Patient and husband will be instructed on transfer, w/c skills, ambulation, and stair climbing strategies to include falls risk reduction and verbal cuing. 3. Daily BID therapy sessions will include: 1. Sensory awareness exercises to increase monitoring of LUE and LLE. 2. Therapeutic exercise to increase voluntary control of LUE, LLE, and L trunk. 3. Functional training for supine to sit, sit to stand, sitting & standing balance, w/c skills, ambulation, and stairs. Based upon the information 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?