Transcript 復健科案例聯合討論會

復健科案例聯合討論會
Intern彭夢婷
Directed by Resident Dr. 陳泰宗
Directed by Attending Dr. 陳芝琪
8H02A
General Data
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Chart No.: 2019784X
Name: 王X豐
Age: 50 years old
Sex: male
Marriage: Single
Occupation: Public servant
Race: Taiwanese
General Data
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Admission Date:
2009/8/2
Transfer Date:
2009/9/7
Hospitalization Days: 44 Days
Rehabilitation Days: 11 Days
Premorbid Functional status: well
Premorbid ADL: independent
Major Diagnosis:
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Traumatic, closed head injury,
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complicated with bilateral SDH of hemisphere
sulci and right frontal ICH,
complicated with brain edema with left midline
shift
Status post
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ICP monitor implantation on 2009/08/03
Right F-T-P craniectomy on 2009/08/04
Right frontal and temporal partial lobectomy to remove ICH on
08/04
Major diagnosis
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Organic brain syndrome, presented with
personality and behavioral changes
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Intermittent disorientation
Self-talking
Restless behavior
Easily hot temper
Agitation
Poor sleep, fair appetite
Underlying disease
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Type II Diabetes Mellitus, newlydiagnosed, under oral hyperglycemic
agents’ control
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Essential hypertension, under fair medical
control
Assessment (8/28 at NS ward)
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Mental status
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Language and Swallowing
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Glasgow Coma Scale: E4 Va M5
Naming: poor
Comprehension: poor
Repetition: poor
Manner: poor
Validity: poor
Swallowing: no dysphasia
Intubation
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No Foley tube, no NG tube, no tracheostomy
Assessment
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Brunnstrom's stage
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upper extremities(P): IV (right)
upper extremities(D): IV (right)
lower extremities:
IV (right)
II (left)
II (left)
II (left)
Muscle Power
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upper extremities(P): 4 (right)
upper extremities(D): 4 (right)
lower extremities:
4 (right)
2 (left)
2 (left)
2 (left)
Assessment
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Functional status
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Katz index of ADL
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Bathing/ dressing/ toileting/ transfer/ feeding/
continence: totally dependent
ANS: Bladder
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Rolling/ sitting/ standing: poor
Ambulation: unable
Incontinence, on diaper
ANS: Bowel
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Incontinence
Rehabilitation Planning
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Physical therapy
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Passive ROM
Stretching training
Endurance training
Ambulation training
Poor rehabilitation potential
Current Medication
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For essential hypertension
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Valsartan 160mg BID
For NIDDM
Metformin 500mg 1# TID
 Gliclazide 60mg 2# BID
 Acarbose 50mg 1# TID
 Sitagliptin 100mg 1# QD
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For Organic brain syndrome
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Quatiepine 25mg 3# IRRE
Assessment (9/7 at 5G ward)
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Urine / stool: incontinence / incontinence, on diaper
No NG tube, no Foley tube, no tracheostomy
Swallowing: no dysphagia
Speech: mild dysarthria
 Comprehension: poor
 fluency/ repetition/ naming: unable
Br. stage: Right Left
Rancho Los Amigos scale
 UE(P):
V
II
Cognitive Level V~VI
 UE(D):
V
II
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V
II
Functional status:
 rolling: good; sitting: fair; standing: poor; walking: unable
Katz index of ADL:
 bathing:D; dressing: A; toileting: D; transfer: D; feeding: A
Assessment (9/14 at 5G ward)
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Urine / stool: continence / continence
No NG tube, no Foley tube , no tracheostomy
Swallowing: no dysphagia
Speech: no dysarthria
 Fair comprehension and spontaneous speech
 Poor fluency/repetition/naming
pressure sore: nil
Rancho Los Amigos scale
Br. stage: Right Left
 UE(P):
VI
IV
Cognitive Level V~VI
 UE(D):
VI
IV
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VI
III
Functional status:
 rolling: good; sitting: fair; standing: poor; walking: poor
Katz index of ADL:
 bathing:A; dressing:I; toileting:A; transfer:A; feeding:I
Barthel index
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進食 (10分)：在合理時間內可自行以湯匙進食。
輪椅與床位間的移位 (10分)：需要稍微的協助或口頭指導。
個人衛生 (5分)：可獨立完成洗臉, 洗手, 刷牙及梳頭髮。
上廁所 (5分)：不會失禁，必要時會自行使用塞劑。
洗澡 (0分)：須別人幫忙
行走於平地上 (10分)：雖無法行走， 但可獨立操縱輪椅並
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推行輪椅五十公尺以上。
上下樓梯 (0分)：無法上下樓梯。
穿脫衣服 (10分)：可自行穿脫衣服及鞋子。
大便控制 (5分)：偶爾會失禁， 每週不超過一次。
小便控制 (5分)：偶爾會尿失禁或尿急， 每週不超過一次。
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總分：六十分
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Rehabilitation Goal
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Goal: Cognition status
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Improve cognitive function
Goal: Functional status
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Improve the ability of standing and ambulation
Goal: ADL
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To achieve ADL partial dependent
Rehabilitation Plan
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Physical Therapy:
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傾斜床訓練: 75度* 30分鐘
促進訓練: 肌耐力訓練
平衡訓練: 坐姿平衡訓練
被動性關節運動與牽拉運動
轉位及移位訓練
運動治療
姿勢擺位與矯正訓練: 軀幹與
頭部控制訓練
Occupational therapy:
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Posture training
ADL training
Moving training
Preceptual and cognitive
function training
U/E and L/E function
training
Thanks for your attention