Traumatic Brain Injury - Case Study Part 3: Difference between revisions
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==Presenting Condition== | |||
For background information go to | |||
[[Traumatic Brain Injury - Case Study Part 1]] | |||
[[Traumatic Brain Injury - Case Study Part 2]] | |||
== Assessment == | |||
=== 6 Months Post Injury === | |||
{| width="800" border="1" cellpadding="1" cellspacing="1" | |||
|- | |||
! scope="col" | | |||
! colspan="2" scope="col" |Upper Limb | |||
! colspan="2" scope="col" |Lower Limb | |||
|- | |||
! | |||
|Left | |||
|Right | |||
|Left | |||
|Right | |||
|- | |||
|Tone | |||
|Increased | |||
|NAD | |||
|Increased | |||
|NAD | |||
|- | |||
|Power | |||
|2/5 | |||
|4/5 | |||
|2/5 Ankle | |||
3-/5 Hip | |||
3-/5 Knee | |||
|4+/5 | |||
|- | |||
|Coordination | |||
| colspan="4" |Impaired | |||
|- | |||
|Range of Movement | |||
Muscle Length | |||
|Shoulder: | |||
Flexion 110° | |||
Abd 90° | |||
IR 40° | |||
ER 50° | |||
Elbow: | |||
Full ROM | |||
Wrist: | |||
Full ROM | |||
|Shoulder: | |||
Full ROM | |||
Elbow: | |||
Full ROM | |||
Wrist: | |||
Full ROM | |||
|Hip: | |||
Full ROM | |||
Knee: | |||
Full ROM | |||
Ankle: | |||
Decreased ROM | |||
DF with Knee Ext -5° | |||
|Hip: | |||
Full ROM | |||
Knee: | |||
Full ROM | |||
Ankle: | |||
Decreased ROM | |||
DF with Knee Ext 0° | |||
|- | |||
|Sensation | |||
| colspan="4" |Unable to participate in formal testing | |||
Does react to some tactile stimulation | |||
|- | |||
|Proprioception | |||
| colspan="4" |Unable to Assess | |||
|- | |||
|Reflexes | |||
|Increased | |||
|NAD | |||
|Increased | |||
Plantar - Upgoing | |||
|NAD | |||
Plantar - Downgoing | |||
|} | |||
=== Current Function === | |||
* No use of oxygen
| |||
* Blood pressure within normal limits
| |||
* Supervision with mat mobility
| |||
* Contact guard with stand turn transfers
| |||
* Contact guard to minimal assist of 1 & supervision of another for gait 1200m
| |||
* Minimal assist of 1 & supervision of 1 on 20 steps reciprocally with a handrail
| |||
* Minimal assist of 1 & supervision of 1 on 6 inch curb
| |||
=== Discharge Planning Considerations === | |||
* Family support | |||
* Environment
| |||
* Equipment
| |||
* Further rehabilitation needs
| |||
== Discussion == | |||
What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can. | |||
[[Category:Course Pages]] |
Latest revision as of 12:21, 2 March 2022
Presenting Condition[edit | edit source]
For background information go to
Traumatic Brain Injury - Case Study Part 1
Traumatic Brain Injury - Case Study Part 2
Assessment[edit | edit source]
6 Months Post Injury[edit | edit source]
Upper Limb | Lower Limb | |||
---|---|---|---|---|
Left | Right | Left | Right | |
Tone | Increased | NAD | Increased | NAD |
Power | 2/5 | 4/5 | 2/5 Ankle
3-/5 Hip 3-/5 Knee |
4+/5 |
Coordination | Impaired | |||
Range of Movement
Muscle Length |
Shoulder:
Flexion 110° Abd 90° IR 40° ER 50° Elbow: Full ROM Wrist: Full ROM |
Shoulder:
Full ROM Elbow: Full ROM Wrist: Full ROM |
Hip:
Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext -5° |
Hip:
Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext 0° |
Sensation | Unable to participate in formal testing
Does react to some tactile stimulation | |||
Proprioception | Unable to Assess | |||
Reflexes | Increased | NAD | Increased
Plantar - Upgoing |
NAD
Plantar - Downgoing |
Current Function[edit | edit source]
- No use of oxygen
- Blood pressure within normal limits
- Supervision with mat mobility
- Contact guard with stand turn transfers
- Contact guard to minimal assist of 1 & supervision of another for gait 1200m
- Minimal assist of 1 & supervision of 1 on 20 steps reciprocally with a handrail
- Minimal assist of 1 & supervision of 1 on 6 inch curb
Discharge Planning Considerations[edit | edit source]
- Family support
- Environment
- Equipment
- Further rehabilitation needs
Discussion[edit | edit source]
What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can.