Traumatic Brain Injury - Case Study Part 2
Presenting Condition[edit | edit source]
For background information go to
Traumatic Brain Injury - Case Study Part 1
Initial Physiotherapy Assessment in the ICU[edit | edit source]
GCS 6 (Eyes 1 Voice 2 Motor 3)
Pupils Right 6+, Left 5+
BP 116/84 Supine
Pulse 114 bpm
O2 Saturation 94% on 30% O2
Upper Limb | Lower Limb | |||
---|---|---|---|---|
Right | Left | Right | Left | |
Tone | Decreased | NAD | Decreased | NAD |
Power | Unable to participate in manual muscle testing
Spontaneous movements are uncoordinated | |||
Coordination | Unable to Assess
Spontaneous Movements Impaired | |||
Range of Movement | Active - No Response to Cues, Spontaneous Movements observed
Passive - Within Normal Limits | |||
Sensation | Unable to participate in formal testing
Does react to some tactile stimulation | |||
Proprioception | Unable to Assess | |||
Reflexes | Decreased | NAD | Decreased
Plantar - Upgoing |
NAD
Plantar - Downgoing |
Behaviour | Restless ++ |
Assessment at 2/12 Post Injury[edit | edit source]
Tracheostomy Removed, Self ventilating on room air.
PEG remains in situ for feeding.
Can attend Gym for Rehabilitation
Currently using wheelchair for mobility
GCS 10 (E4 V2 M4) Not following commands, No speech but occasional physical aggressive outburst
Mask like expression of face, wide open eyes and constantly raised eyebrows giving an alarmed or surprised impression, consistent with abnormal tone and sensation
Poor eye contact
Flexed posture with poor trunk and head control
Repetitive non purposive movements of RLL
Subluxation of Left GHJ (Two Fingers Breadth)
Upper LImbs | Lower Limbs | |||
Left | Right | Left | Right | |
Tone | N | N | ||
Power | 0/5 | 4/5 | 0/5 Ankle
1/5 Hip 1/5 Knee (Not to Command) |
4/5 |
Sensation | Unable to Assess | |||
Coordination | Unable to Assess - During Spontaneous Movements Cordination Impaired | |||
Proprioception | Unable to Assess | |||
Reflexes | ¯ | ¯ | ||
ROM
Muscle Length |
Glenohumeral Joint (GHJ);
External Rotation 45° Internal Rotation 40° Flexion 90° Abduction 60° *Painful Grimace at End of Range GHJ Movement Elbow Full Range of Movement Wrist Full Range of Movement |
Full Range of Movement All Joints | Hip Full
Knee Full Decreased Achilles Length
|
Hip Full
Knee Full Decreased Achilles Length
|
Function
Staticic | Dynamic | |
Sitting Balance | Assist x 2 | Unable - Tends to Extend |
Standing Balance | Max Assist x 2 | Unable - Tends to Extend |
Bed Mobility | Assist x 2 | |
Lie to Sit | Assist x 2 | |
Sit to Stand | Max Assist x 2 - Tends to Extend | |
Gait | Unable to Initiate | |
Wheelchair | Dependant - Currently in Tilt in Space | |
ADLs | Dependent for All |
Considering what we now know, outline the key impairments and activity limitations for James. What outcome measures might you use with James and why? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can. Go to Discussion.