Monday, October 4, 2010
Monday, June 21, 2010
Monday, May 10, 2010
I had been working with a patient, who was admitted from home after having a fall and came into hospital with a UTI.
I had completed a SAP with her, and reviewed her pre and current occ performance and decided to see her after the weekend to organise a h/v due to her hx of falls and her decline in mobility.
I had documented this in the notes and then attended the MDT mtg on Monday. When the doctor talked about this patient he really had no idea about this patient (her background, falls hx, and how she was managing).
He said I think we need to look at rehab for this lady. I spoke up by saying “I don’t think she is far off her baseline/preadmission occ performance I mentioned that I had planned to do a home visit with this patient early week to assess her safety at home.. But I was not listened to. The doctor asked the “us” (looking at the PT) to review her ?appropriate for rehab.
The next day, I reviewed the notes and the PT had not analysed the plan. i.e. had not mentioned if she was appropriate or not for rehab. I asked the PT how her session went with the patient.
She replied “you were right she is much better this week, probably not appropriate for rehab as yes I think this is how she was before she came in”. I wondered to myself – well why didn’t you document that.
I documented the discussion and met with the patient to get her perspective of being ready for going home, she agreed she was ready and also gave consent for a f/u home visit one day post to ensure she was in a safe environment.
My reflection on this:
I felt I wasn’t being listened to in the MDT with regards to the OT perspective and plan.
I realise one of my roles is “discharge planner” however, I felt in this situation that I was the co-ordinator between PT, and OT – almost summarising the input and sorting the plan for discharge. I felt like I was going over and beyond to sort this lady out – for a few reasons
The medical team didn’t listen to me re: my input and plans from OT perspective
The PT’s analysis wasn’t clear.
How could I have dealt with this better? What will I do next time?
I could have asked the PT to document her view of ?appropriate for rehab as asked in the MDT, however I think it was still appropriate to document that we had that discussion.
I could have talked to the medical team post MDT re: the OT plan
I could have provided feedback to the MDT i.e. The OT and PT had been working with the patient, and that if we felt necessary we would talk to them about rehab appropriateness.
Basically I wanted to say that I felt undermined and that my input was irrelevant – Maybe I should have said that to the Dr/Consultant – knowing that perhaps that could have had a negative impact on OT
Monday, April 19, 2010
I had a patient with Macular Degeneration that I would like to discuss and learn more
Thursday, April 15, 2010
The posterior portion of the corpus callosum is called the splenium; the anterior is called the genu (or "knee"); between the two is the truncus, the 'body' of the corpus callosum. The rostrum is the portion of the corpus callosum that projects posteriorly following from the anteriormost genu.
Thinner axons in the genu interconnect prefrontal cortex areas between the two sides of the brain. Those in the posterior body of the corpus callosum interconnect parietal lobe areas. Thicker axons in the midbody of the corpus callosum and in the splenium interconnect areas of the motor,somatosensory, and visual cortex.
Using magnetic resonance diffusion tensor imaging, the studies of Hofer and Frahm  suggest that the anterior sixth of the corpus callosum interconnect the prefrontal parts of the brain; the next third, the premotor and supplementary motor regions; the following sixth, the motor areas; then the next twelfth deals with the sensory areas; and the final quarter, the parietal, temporal, and occipital lobes.
- Alien hand syndrome
- A complete or partial absence of it in humans is called agenesis of the corpus callosum.
- Septo-optic dysplasia (deMorsier syndrome)
- Alexia without agraphia (seen with damage to splenium of corpus callosum)
Split-brain is a lay term to describe the result when the corpus callosum connecting the two hemispheres of the brain is severed to some degree. The surgical operation to produce this condition is called corpus callosotomy and is usually used as a last resort to treat intractable epilepsy. Initially, partial callosotomies are performed; if this operation does not succeed, a complete callosotomy is performed to mitigate the risk of accidental physical injury by reducing the severity and violence of epileptic seizures. Prior to callosotomies, epilepsy is treated through pharmaceutical means.
A patient with a split brain, when shown an image in his or her left visual field (the left half of what both eyes take in, see optic tract), will be unable to vocally name what he or she has seen. This is because the speech-control center is in the left side of the brain in most people, and the image from the left visual field is sent only to the right side of the brain (those with the speech control center in the right side will experience similar symptoms when an image is presented in the right visual field). Since communication between the two sides of the brain is inhibited, the patient cannot name what the right side of the brain is seeing. The person can, however, pick up and show recognition of an object (one within the left overall visual field) with their left hand, since that hand is controlled by the right side of the brain.
The same effect occurs for visual pairs and reasoning. For example, a patient with split brain is shown a picture of a chicken and a snowy field in separate visual fields and asked to choose from a list of words the best association with the pictures. The patient would choose a chicken foot to associate with the chicken and a shovel to associate with the snow; however, when asked to reason why the patient chose the shovel, the response would relate to the chicken.
Alexia without agraphia is a form of alexia which almost always involves an infarct to the left posterior cerebral artery (which perfuses the splenium of the corpus callosum and left visual cortex, among other things).
The resulting deficit will be "Alexia without agraphia" - i.e., the patient can write but cannot read (even what they have just written). This is because the left visual cortex has been damaged, leaving only the right visual cortex (occipital lobe) able to process visual information, but it is unable to send this information to the language areas (Broca's area, Wernicke's area, etc) in the left brain because of the damage to the splenium of the corpus callosum. The patient can still write because the pathways connecting the left-sided language areas to the motor areas are intact.
In most tests, memory in either hemisphere of split-brained patients is generally lower than normal, though better than in patients with amnesia, suggesting that the forebrain commissures are important for the formation of some kinds of memory. It is suggested that posterior callosal sections which include the hippocampal commissures cause a mild memory deficit (in standardized free field testing) involving recognition.
In general, split-brained patients behave in a coordinated, purposeful and consistent manner, despite the independent, parallel, usually different and occasionally conflicting processing of the same information from the environment by the two disconnected hemispheres. When two hemispheres receive competing stimuli at the same time, the response mode tends to determine which hemisphere controls behavior. Often, split-brained patients are indistinguishable from normal adults. This is due to the compensatory phenomena; split-brained patients progressively acquire a variety of strategies to get around their interhemispheric transfer deficits.
Experiments on covert orienting of spatial attention using the Posner paradigm confirm the existence of two different attentional systems in the two hemispheres. The right hemisphere was found superior to the left hemisphere on modified versions of spatial relations tests. The components of mental imagery are differentially specialized: the right hemisphere was found superior for mental rotation, the left hemisphere superior for image generation.
Infarcts of the corpus callosum are not common and are attributed to a rich blood supply from three main arterial systems: the anterior communicating artery, the pericallosal artery, and the posterior pericallosal artery (4). A detailed description of the vascular supply to the corpus callosum was published by Ture et al (5), including variations in the main arterial supply. The pericallosal branch of the anterior cerebral artery is most often the main vascular supply to the body. The subcallosal and medial callosal arteries, branches of the anterior communicating artery, provide the main supply for the anterior portion of the corpus callosum. The posterior pericallosal artery, a branch of the posterior cerebral artery, supplies the splenium.
Chrysikopoulos et al (4) offer other possible explanations for the immunity of the corpus callosum to infarction. Isolatedinfarcts of the anterior and posterior cerebral arteries are uncommon, accounting for 12% of all infarcts, and when presentare found in conjunction with generalized atherosclerotic disease. All of the patients in our series had long histories of hypertension and three of the five patients had insulin-dependent diabetes mellitus, predisposing them to generalized atherosclerosis. Chrysikopoulos et al (4) note that the majority of strokes are thromboembolic in origin, and emboli tend to favor the middle cerebral artery distribution because of hemodynamic factors. Moreover, the penetrating vessels of the corpus callosum are small in size and generally run perpendicular to the parent artery, thus protecting the corpus callosum from emboli.
Kazui et al (6) found in their series that infarction localized to the anterior cerebral distribution was attributable mostcommonly to local atherothrombosis and occasionally to cardiogenic embolism. They also postulate that a hypoplastic A1 segment may facilitate the occurrence of embolism in the anterior cerebral artery distribution. MR angiography performed in one of the patients in our series (case 2) showed small anterior cerebral arteries relative to the other cerebral vessels. This was of uncertain etiology. Although stenosis was considered, no conventional angiogram was obtained.
Chrysikopoulos et al (4) found that the splenium of the corpus callosum was affected more often than was the body and genu. They attributed this to the greater incidence of posterior cerebral artery infarcts compared with anterior cerebral artery infarcts. In our series, all of the lesions involved the genu, body, or both, whereas none involved the splenium. The difference in the location of the infarcts in our study, as compared with that reported by Chrysikopoulos et al, may be due to the difference in the patient population; ie, patients with diabetes and hypertension develop generalized atherosclerosis, which in turn increases the incidence of anterior circulation infarction. Isolated anterior cerebral artery infarcts are rare, accounting for 0.6% of all cerebral infarcts (6). Chrysikopoulos et al (4) found evidence of hemorrhage in about 25% of their cases, whereas there was no evidence of hemorrhage in any of our cases. Thus, the presence of hemorrhage may suggest infarct, but the absence of hemorrhage should not exclude the diagnosis. Infarcts of the corpus callosum may exhibit a variable degree of mass effect. Mass effect is commonly seen in stroke, but when it occurs in a region such as the corpus callosum where stroke is often not considered, it suggests other entities that would require biopsy. Enhancement is often seen by the end of the 1st week and can persist for many weeks (7, 8). In many of our cases, the abnormal signal intensity or enhancement or both crossed the midline, unusual for infarct but not for tumor.
Clinically, infarcts of the corpus callosum are frequently associated with neuropsychiatric symptoms, mainly interhemispheric disconnection syndromes (9). In addition, specific syndromes such as dyspraxia contralateral to a paretic limb (10, 11) and alien hand syndrome (12, 13) have been reported, and an isolated gait disorder has been described in relation to lacunes in the anterior portion of the corpus callosum (12).
Wednesday, April 14, 2010
Saturday, April 10, 2010
Monday, March 22, 2010
Polyarticular Gout. If more than one joint is affected, it is known aspolyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.
An untreated attack will typically peak 24 - 48 hours after the first appearance of symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.
Reason for admission - Methylprednosone Pulses 3x
Reason for Referral Assessment - Splinting, Education, RTW, equipment/aids
- Intial Hand Assessment
- ADL tasks sheets- self report of difficulties
- Assessment of Hands
- Pain and reduced ROM in R) Wrist - also decreased strenght in R) hand
- Swan neck deformity in R) LF
- Pain in TMC/CMC joint - thumb
- Difficulties with multiple ADLS
- Reduced mobility due to pain in L) knee; both ankles and feet.
- Poor sleep and fatigue
- Mobilising with gutter crutch L) arm
- Independent with personal ADL's on ward, concerns re: showering at home
- Unable to carry heavy items or carry items in R) hand
- No completeing heavy housework tasks
- Difficulty with but independant with multiple actions/tasks at home relating to hand function, strenght, pain and immobility
- Education re: sleep cycles, factors linking to poor sleep, strategies and use of relaxation, sleep diary and routine/environmental setup
- Wrist splint - D ring splint for stability
- Issued a BB and K-trolley
- Book in O/P clinic to review splinting of R) LF - swan neck deformity, and resting slint for wrist.
Monday, March 15, 2010
- Prompt to start task
- Indep with manipulating toothpaste - fine motor
- Chose appropriate tools and used them appropriately
- Assistance gathering and organising task environment - therapist intitated
- Sitting in chair, stabilising body on table
- Assistance to position table appropriately to perform task
- Coordinating bilateral hand tasks effectively
- Reduced grip strength ? due to arm positioning akwardly
- Obtaining and holding task objects effectively
- Poor endurance throughout task
- Pace slow, however ? due to difficulty with terminating task
- Attends to task, however distracted by others talking, however contiunes with tasks indep
- Handles task objects appropraitely
- Sequencing task appropriately
- Repeats steps ? difficulty terminating task
- Searches and locates objects
Sunday, March 7, 2010
Friday, March 5, 2010
For many years it was thought that fibromyalgia was psychologically based but is now recognised as a medical condition in its own right and research into the condition has increased.
Approximately 80% of fibromyalgia sufferers are women and the condition is most commonly diagnosed in the 30 to 45 year age group.
It is thought that fibromyalgia may be due to a malfunction in the way the central nervous system processes pain signals. This leads to people with fibromyalgia experiencing as pain, sensations that other people might perceive as uncomfortable.
Two brain chemicals, Serotonin and Substance P, are thought to play a role in the condition.
Serotonin is a neurotransmitter (a chemical that enables the transmission of nerve impulses) that influences mood, appetite, pain perception, sexual function, anxiety, temperature control and sleep. Studies have indicated that levels of this chemical are lower than usual in people with fibromyalgia.
The one symptom experienced by everyone with fibromyalgia is pain. This pain can be described in various ways, such as an ache, a sharp pain, a throbbing or a burning feeling. The pain is felt throughout the body and on both sides of the body. The pain can move from one part of the body to another. The amount of pain experienced can vary throughout the day and can also worsen with a change in weather, increase in stress, noise, activity and lack of sleep.
Stiffness of muscles and joints is most noticeable in the morning and after a period of rest. This can interfere with work and daily activities such as driving. Keeping moving is the best way to prevent stiffness. If a person has to sit for long periods, he or she can reduce stiffness by regularly getting up to move around and stretch.
Fatigue is experienced by up to 90% of people with the condition. The level of fatigue can vary from person to person, from being barely noticeable to severe. As with the amount of pain experienced, the degree of fatigue can vary throughout the day, from day to day, and may even be absent on occasion.
Many people with fibromyalgia experience sleep problems. There are a number of stages of normal sleep ranging from light to deep sleep. It seems that people with fibromyalgia often lack the deep restorative stages of sleep and often wake feeling unrefreshed.
Over half of people with fibromyalgia experience symptoms such as irritability, forgetfulness, lack of concentration, mood changes, anxiety and depression.
Other symptoms that can be experienced by people with fibromyalgia include:
- Migraine and tension headaches
- Recurrent abdominal pain
- Difficulty swallowing
- Irritable bladder leading to frequent or painful urination
- Numbness and tingling of the extremities
- Dry eyes and mouth.
In order to make a diagnosis of fibromyalgia the doctor will look for the following indicators of the condition:
- A history of widespread pain
- At least 11 of 18 specific tender point sites (as shown below)
- Normal blood tests
- Chronic fatigue
- Sleep disturbances
- Skeletal pain (mainly in the neck and back).