Stiff Person Syndrome: A Case Study: Difference between revisions
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Introduction | == Introduction == | ||
== Client Characteristics == | |||
Mr. Reed is a 75-year-old male. He is a retired data analyst, who lives at home with his wife in Kingston, Ontario. Mr. R began noticing he had decreased balance two and a half years ago with increased amounts of falls (last fall ~two weeks ago) which has progressively gotten worse with low back pain starting a year and a half ago. Within the last year he noticed increased pain in his lower extremities with muscles spasms particularly affecting the left leg. He was referred to a neurologist and diagnosed with SPS. He received a referral for outpatient physiotherapy to perform a falls risk assessment, help with his balance and gait, manage muscle rigidity and spasms, and maintain his independence and quality of life. | |||
== Examination Findings == | |||
=== Subjective === | |||
* '''Patient Profile (PP):''' 75 y/o male, right hand dominant | |||
* '''History of Present Illness (HPI):''' diagnosed with stiff person syndrome 1 year ago, left plantar flexor contracture (~2 months), muscle spasms, and progressive rigidity (~ 1 year) and lower extremity pain (~6 months), chronic low back pain (~1.5 years). | |||
* '''Past medical history:''' Type 1 diabetes, hypertension, high cholesterol. | |||
* '''Medications:''' Oral diazepam, gabapentin (1), and insulin | |||
* '''Health Habits:''' Non-smoker, drinks occasionally (~2 drinks a week). | |||
* '''Psychosocial:''' The patient describes feeling lonely due to COVID-19 as well as frustrated with the diagnosis. Over the past 6 months he has avoided gardening and groceries due to feeling unsteady and having a fear of falling. He lives with his wife and his son lives 20 minutes away and visits weekly where his daughter lives 1 hour away and visits monthly. | |||
* '''Home:''' Bungalow, 5 stairs into home with railings on the right at both front and back door. The bathroom has a stand up shower with railings. | |||
* '''Previous Functional Status:''' Able to ambulate more than 200m with no gait aid, active in gardening and golfing, no issues performing activities of daily living (ADLs) | |||
* '''Current Functional Status:''' Less confident walking outdoors, feeling unsteady, rigidity and painful spasms in both lower extremities prevented him from engaging in his hobbies (gardening, watching golf, sailing) | |||
* '''Imaging/Diagnostic testing:''' MRI and X-ray for chronic low back pain (all negative), Blood tests (Anti-GAD body 92.5 units/mL), nerve conduction studies (No abnormalities) | |||
* '''Precautions/Contraindications:''' None | |||
* '''Chief complaint:''' decreased balance control, increased rigidity and painful spasms in lower extremities particularly in the left leg limiting his ability to do ADLs. | |||
Revision as of 04:30, 13 May 2021
Introduction[edit | edit source]
Client Characteristics[edit | edit source]
Mr. Reed is a 75-year-old male. He is a retired data analyst, who lives at home with his wife in Kingston, Ontario. Mr. R began noticing he had decreased balance two and a half years ago with increased amounts of falls (last fall ~two weeks ago) which has progressively gotten worse with low back pain starting a year and a half ago. Within the last year he noticed increased pain in his lower extremities with muscles spasms particularly affecting the left leg. He was referred to a neurologist and diagnosed with SPS. He received a referral for outpatient physiotherapy to perform a falls risk assessment, help with his balance and gait, manage muscle rigidity and spasms, and maintain his independence and quality of life.
Examination Findings[edit | edit source]
Subjective[edit | edit source]
- Patient Profile (PP): 75 y/o male, right hand dominant
- History of Present Illness (HPI): diagnosed with stiff person syndrome 1 year ago, left plantar flexor contracture (~2 months), muscle spasms, and progressive rigidity (~ 1 year) and lower extremity pain (~6 months), chronic low back pain (~1.5 years).
- Past medical history: Type 1 diabetes, hypertension, high cholesterol.
- Medications: Oral diazepam, gabapentin (1), and insulin
- Health Habits: Non-smoker, drinks occasionally (~2 drinks a week).
- Psychosocial: The patient describes feeling lonely due to COVID-19 as well as frustrated with the diagnosis. Over the past 6 months he has avoided gardening and groceries due to feeling unsteady and having a fear of falling. He lives with his wife and his son lives 20 minutes away and visits weekly where his daughter lives 1 hour away and visits monthly.
- Home: Bungalow, 5 stairs into home with railings on the right at both front and back door. The bathroom has a stand up shower with railings.
- Previous Functional Status: Able to ambulate more than 200m with no gait aid, active in gardening and golfing, no issues performing activities of daily living (ADLs)
- Current Functional Status: Less confident walking outdoors, feeling unsteady, rigidity and painful spasms in both lower extremities prevented him from engaging in his hobbies (gardening, watching golf, sailing)
- Imaging/Diagnostic testing: MRI and X-ray for chronic low back pain (all negative), Blood tests (Anti-GAD body 92.5 units/mL), nerve conduction studies (No abnormalities)
- Precautions/Contraindications: None
- Chief complaint: decreased balance control, increased rigidity and painful spasms in lower extremities particularly in the left leg limiting his ability to do ADLs.
