Traumatic Brain Injury - Case Study Part 3
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 | Decreased | NAD | Decreased | 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 | Decreased | NAD | Decreased
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 1200’
• 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.
