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Case Study of a stroke patient. The National Hospital for Neuroscience and Neurosurgery

Case Study of a stroke patient. The National Hospital for Neuroscience and Neurosurgery. By Sarah Hart U0604985. Learning Objectives. Introduce the patient and their presenting condition.

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Case Study of a stroke patient. The National Hospital for Neuroscience and Neurosurgery

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  1. Case Study of a stroke patient. The National Hospital for Neuroscience and Neurosurgery By Sarah Hart U0604985

  2. Learning Objectives • Introduce the patient and their presenting condition. • Explain what a stroke is signs and symptom in this case with particular reference to the Pontine and Reticulospinal tracts. • Explain the initial assessment and goals set by the MDT team for the patient

  3. History andPresenting Condition • Patient is a 72yr old gentlemen. • BIBA LAS to UCLH 14/7/08 with slurred speech, reduced power in left arm and leg, after being found on the floor at 1pm that afternoon in his hotel. • O/E- pt was found to have Dysarthria, Right Upper Motor Neurone facial palsy, hypoglossal nerve palsy, Left hemiplegia, confusion, and global hyper-reflexia

  4. Previous IHD Hypothyroidism Cataracts Chronic Renal Impairments New medical problems that have come to light since admission:- Hyper cholesterol And on MRI- Old R posterior cerebral territory infarct. Past Medical History

  5. Social history Until fours years ago was living with parents in a council house, after the patient parent died the patient moved into a hotel. Previous mobilising independently Relied on staff at hotel for domestic duties. Drug history Aspirin Since admission- Simvastatin Levothyroxine Further information

  6. Cerebral vascular accident (CVA) • Definition- By the WHO as ‘rapidly developing clinical signs of focal cerebral function with symptoms lasting more than 24hrs or leading to death, with no apparent cause other than the vascular origin’ (Smith 1997)

  7. Pontine

  8. Reticulospinal Tract • Descending motor pathways that originate in the pontine and medullary reticular formation and project to medial ventral horn neurons. These pathways are involved in modulating postural adjustments and gait-related movements.

  9. Key aspects to a successful rehabilitation for Strokes • Based on the “National Service Framework for Long-term Conditions. DoH 05 • Prevention • Acute management • Rehabilitation • Transfer to the community • Long-term support • Service Organisation

  10. Initial assessment NHNN • From initial assessment sensation proprioception were intact. • Proximal weakness bilaterally L>R. • Reduce co-ordination due to reduced proximal muscle control. • Bed mobility and transfer were slightly impulsive, required assistance/supervision • Outcome measures to be used- Berg Balance.

  11. Impairments Proximal muscle weakness L>R Reduced co-ordination of movement Reduced balance mechanism Participation and Activities Dependant on assistance of 2 to mobilise Unable to manage stairs Requires increased time to complete personal care tasks Dependant for domestic tasks WHO Guidelines

  12. Short term goals • MDT Assessments to be completed and goals set. Goals are individual focused. • Leading on from the impairments list, initial physio goals that have been set are:- • To transfer from the bed to the chair safely and independently. • Mobilising with assistance of one over 50m. • Able to complete a flight of stairs ascending and descending with assistance of two progressing to assistance of one.

  13. Medium term goals • MDT plan D/C, Referrals on to stroke units in the patient borough • Possible physio goals:- • Able to mobilise independently on the ward with close supervision. • Able to mobilise to bathroom alone. • Able to complete a flight of stairs ascending and descending with assistance of one progressing to close supervision. • Assess whether the patient would be suitable for a walking aid or not.

  14. Long term goals • MDT approach, management of secondary prevention. • Reassess for further targeted rehabilitation. These decisions are based on evidence based practise (Stokes 2004). • Possible physio goals:- • Outdoor mobility, negotiating curbs and different terrain. • Able to complete stairs safely without supervision.

  15. References • DoH 05 National Service Frameworks for Long term Conditions. • Smith, M.T., Baer, G.D., (1997). Measuring the outcomes for specific stroke sub-types using simple mobility milestones, Physiotherapy, 83, 254 • Stokes, M, (2004) Physical Management in neurological Rehabilitation, Elsevier, London • http://www.stroke.org.nz/assets/ischaemic_stroke_sml.gifwww.stroke.org.nz Brain picture.

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