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.

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