Wednesday, June 10, 2009

Case Review

I have an interesting case at the moment - well kind of complex

She is a 77 year old that as had numerous admissions to hospital over the last year. This admission was not directly linked to why she was referred to me. She was referred to me because she was presenting as very confused on the ward and repeating things that she had talked about already.
I went to see the patient and she presented rather "different". There was something about her that i couldn't pin point. She made a cup of milo indpendanly and safely on the ward but i chose to re-assess as i wasn't happy with the assessment data that i had gather.
I chose to do a standardised assessment - Hierarchic Dementia Scale. The results concluded that this patient had a severe short term memory impairment and mild-moderate attention/concentration, registration and long term memory issues.
From here i was concerned about the patients ability to manage in the community as she was home alone all day and was required to attend to personal cares, taking medications, and preparing lunch/breakfast throughout the day. So i decided to do a more complex functional task - preparing and light meal. From my observations she required assistance with searching and locating items (which shouldn't be problematic in a familiar environment) and remembering each instruction i had asked her to do e.g. "please can you make a pouched egg pn a piece of toast, present it on the table, and make a cup of tea to have with your meal...when you are finished can you please tidy up after you. The patient safely and Indep. prepared the meal but required prompting to tidy up. At times the patient became distracted and lost attention - pausing in the middle of the task - it was like she was thinking about what to do next - however she independently continued on with the task without prompting. I have no concerns about her ability to prepare simple meals and went back to talk to the team about my concerns about discharge

(1) - taking medications
(2) - managing finances

The team thought that a family meeting was appropriate so i went to contact the SW and family to organise this.
I got lots of useful information about the patient from contacting the family.

-The ST memory had been concerning them - she was been experiencing this for about 4-5 months however it has declined since her stroke about 6 weeks ago.

-They were concerned about her discharge location and the support that her partner could provide - as her partner had mentioned that he didn't know if he could cope with her ST memory decline - repetitiveness...

The goal of the family meeting is to
a) sort out discharge destination
b) sort out appropriate support for the patient - family or services

All will be relieved tomorrow - however this may take a bit of working with the family as it potentially could be a complex situation


Friday, June 5, 2009

File:Spinal nerve.svg - Wikipedia, the free encyclopedia

File:Spinal nerve.svg - Wikipedia, the free encyclopedia

Sensory pathway - posterior/dorsal column

The posterior column-medial lemniscus pathway (dorsal column-medial lemniscus pathway) is the sensory pathway responsible for transmitting fine touch, vibration and conscious proprioceptive information from the body to the cerebral cortex.[1]

The name comes from the two structures that the sensation travels up: the posterior (or dorsal) columns of the spinal cord, and the medial lemniscus in the brainstem. Because the posterior columns are also called dorsal columns, the pathway is often called the dorsal column-medial lemniscus system, or DCML for short. (Also called posterior column-medial lemniscus or PCML pathway).

Observing some stroke patients and beginning input with stroke patients

I have had the opportunity to see a stroke patient today - she wasnt under the stroke team but her MRI came back with 2 R) Cerebellar infacts and CT results showed small ischaemic haemorrages.
Interestingly the patient had an inner ear infection about a month ago and her initial symptoms were suggestive of problems with inner ear - e.g. balance disturbance and dizziness...However she also had a headache and heart palipitations and ended up in hospital after collapsing (although not loosing conciousness).

I reviewed her notes and spent some time reviewing what had been happening for the patient. I had the opportunity to observe the registrar completing some sensory tests which was quite exciting.
She tested proprioception (asking the patient to close her eyes and describe the movement she was making with her metatarsel joint.
She tested vibration sense - with a metal fork that she banged and held on he joint asking the patient to identify when the vibration was present and when it stopped. I had the opportunity to experience what this sense felt like and the consultant was very helpful and also did a few other sensory tests on me
He did some sound and hearing tests with the vibration fork asking me to identify what sound of the fork was louder. He also put the end of the fork on my forehead and asking me to tell me what side was louder (was ment to be the same level of sound - which it was - so im normal)
The registrar also tested touch - with prick and dull pressure
The consultant tried to explain to me the senses they test for and it brought back some of the learning from teck about the spinal cord and the columns and which sense is associated with each - this interested me and i felt like looking this up on the net!
Next post will follow !!!!!!!!

As for my experience assessing this patient - her main issues were balance disturbance and fatigue
I completed an initial assessment wth the patient and identified any pre-dysfunction - good thing i did this becuase she had had a carpel tunnel repair to her effected side and this had already weakened her R hand strength.. She had no concerns about managing at home and the PT had assessed that she was safe for discharge with PT comm f/u.
I reviewed her function on the ward and set her home up for discharge, educated the patient on energy conservation etc.
After talking to my supervisor she took this a step further and we talked about fatigue diary as the patient still works and is keen to return to work as soon as possible. I plan to ring the patient next week and educate her on this

Fatigue diary - to rate the level of fatigue (am, late am, lunch, mid pm, late pm, bedtime) at various times and when doing activity. This aims to increase insight into fatigue levels during certain times of the day and during/after certain activities....then they can hopefully apply some energy conservation techniques to help control fatigue...

I also had the opportunity to observe the PT assessment - balance, gait, steps, nose finger (with increasing speed) and heel shin rub etc - it would be good if i could talk to the PT about what some of the more complex assessments were testing specifically - quite an interesting afternoon today!