Bethany Case Study

7/30/2019 Bethany Case Study

1/25

Lara Albano, Patricia Gelling,Gretchen Kempf, Dominique

Keogh, Laura Mammato, Megan

McCarthy, Laura Van

Volkenburg and Christina Weiss

May 7, 2013


2/25

Diagnosis: astrocytoma; s/p craniotomy at NYU Date of onset: 12/24/13

Date of treatment: 2/4/13

Rehab diagnosis: brain tumor with right internal

capsule strokeaftersurgery Precautions: falls, diplopia, and foot drop

Prior level of function: independent in all dailyactivities

Pt. stated goal: To be a normal person againTo playpiano, swim, and bowl.

Chief complaint of symptoms: weakness in both UEs,vision difficulties, and difficulty getting aroundoutside and at home.


3/25

History of present illness: Pt. underwent a craniotomy at NYU 12/24/12 secondary

to an aggressive brain tumor

Pt. suffered a right internal capsule stroke with left

progressive lower extremity spasticity Brain tumor was diagnosed after MRI secondary to falls,

rapid onset of upper extremity weakness, and double

vision

Tumor was not removed and requires monitoring forincrease growth


4/25

Hand dominance: Right

Area of pain: posterior shoulder capsule on left and left sideof vertebral border of scapula since the surgery was

performed

Nature: dull and achy

Duration: intermittent Intensity on average: 5-6 out of 10

PMH: Unremarkable

Social and Work history: Resides in a two-story home with

parents and two sisters. Pt. is homeschooled. Mother is homeduring the day. Pt. enjoys swimming, shopping, outdoors,

playing the piano, and scrapbooking. Pt. has chores she is

responsible for but unable to do at present time.

Driving status: non-driver at present time


5/25

PROM in left and right UE is WNL AROM in right UE is WNL for everything except shoulder

abduction and flexion

Fair plus L forearm supination/pronation, L wrist radial/ulnardeviation, R shoulder extension, internal rotation and

external rotation, and R elbow flexion/extension

Good minus in R forearm pronation/supination, R wristflexion/extension, and R wrist radial/ulnar deviation

Tone is normal in trunk and left and right UE, and Bethanyhas isolated joint movement with near normal coordination

Good control of head position in midline

Sensation is fully intact

Bethany is independent in: feeding, grooming, clothingmanagement, bed mobility, and toileting.

Bethany is modified independent in dressing and bathing


6/25

Precautions: Falls; Diplopia; Foot Drop

Pain: Left posterior shoulder capsule and left side vertebralborder of scapula. Described as dull and achy intermittently

with an average of 5-6 on the pain scale.

Movement Analysis: Bilateral weakness in upper extremities

(left more affected)

Slight ataxia and delayed fine and gross movement patterns

Scapular Position: Left-side depressed, protracted,

downwardly rotated

Trunk Position: Posterior pelvic tilt. Increased weight bearing

on right side with elongation there, shortening on left Vision difficulties: diplopia (corrective lenses assist);

decreased depth perception

Grasp: Decreased in left hand

Most affected IADLs: Homemaking tasks and functional

mobility/transfers


7/25

Shoulder

Abduction: 0-75 (norm 0-180)

Flexion: 0-60 (norm 0-180)

Extension: 0-40 (norm 0-60)

Internal Rotation: 0-20 (norm0-70)

External Rotation: 0-35 (norm0-90)

Elbow

Flexion/extension: 0-120(norm 0-150)

Forearm

Pronation: WFL (norm 0-80)

Supination: 0-35 (norm 0-80)

Wrist

Extension: 0-15 (norm 0-80)


Radial deviation: 0-10 (norm

0-20) Ulnar deviation: 0-20 (norm 0-

30)

Thumb

Palmar abduction: 0-45

Radial abduction: 0-35

MCP: 0-40 (norm 0-50)

IP: 0-50 (norm 0-80)

Digits: WFL

Left UE (involved side) AROM (PROM is WNL)


8/25

Right UE (PROM is WNL)

Shoulder

Abduction: 0-145 (norm 0-180)


*Rest of R UE AROM is WNL* Distal Palmar crease measurement and finger opposition

are WNL


9/25

Left UE Strength (involved side) Right UE Strength

Fair plus : forearm

pronation/supination,

wrist radial/ulnar

deviation

Fair: elbowflexion/extension, wrist

flexion/extension

Poor minus: shoulder

flexion/extension,

shoulder abduction,shoulder internal/external

rotation

Good minus : wrist

flexion/extension, wrist

radial/ulnar deviation,

forearm

pronation/supination Fair plus : elbow

flexion/extension,

shoulder extension,

shoulder internal/external

rotation Fair: shoulder abduction,

shoulder flexion


10/25

Fatigue noted throughout ADL evaluation

ADLs

Feeding = Independent

Grooming = Independent UE & LE Dressing = Modified Independence

Bathing = Modified Independence

Clothing Management = Independent

Toileting = Independent


11/25

ADL

-Functional Mobility = Minimal Assist/Contact

Guard

-Bed Transfer = Contact Guard

-Toilet Transfer = Contact Guard

-Tub Transfer = Contact Guard

-Bed Mobility = Independent

IADLs

All homemaking tasks (cooking, cleaning,

laundry, shopping, and financial management)

required Max Assistance.


12/25

Pain Analog Scale

ROM/MMT

Trunk and UE Neurological Assessment

normal tone on right and left sideModified Ashworth Scale for Grading

Spasticity No increase in muscle tone

UE Neurological Assessment Head in midline with good control, scapular

depression, downward rotation and protraction,posterior pelvic tilt and elongation on the rightside.


13/25

9 hole peg test Right-45 secs.

Left-2 min. 10 sec.

Minnesota Placement Right-2 min. 15 sec.

Left-5 min. 14 sec.

FIM

Visual Screening Has corrective lenses,

but diplopia is presentwith decreased depthperception

Hand strength

gross grasp:

Right-50 lbs.

Left-25 lbs.lateral pinch:

Right-12 lbs.

Left-4 lbs.

3 jaw chuck:

Right-14 lbs.Left-6 lbs.

tip to tip pinch:

Right-8 lbs.

Left-3 lbs.


14/25

Berg Functional Balance Scale

To evaluate Bethanys sitting and standingbalance.

Beck Depression Inventory 21-question multiple choice self-report inventory

widely used for measuring depression. This can

assess Bethanys level of depression and

psychosocial status after her brain tumor,craniotomy and stroke.


15/25

Patient will increase her endurance, requiring less than 3 restbreaks during a therapeutic activity to assist with leisure

activities.

Patient will increase tip-to-tip pinch in her L hand by 3-5lbs to

assist with putting her contacts in.

Increase bilateral shoulder strength by a half grade to assist with

UE and LE dressing and transfers.

Decrease pain from 5/10 to 2/10 to allow more independence in

overhead dressing and transfers.

Patient will improve gross grasp of her L hand by 10-15 lbs toincrease from maximum assistance to moderate assistance with

home chores. Increase AROM in proximal L UE by at least 10-15 degrees to assist

with engagement in shopping activities.

Patient will maintain sitting in midline for 2 minutes to increase

trunk control for playing the piano.

Increase lateral pinch by 2-3 lbs to assist with scrapbooking.


16/25

Patient will increase AROM of her proximal L

shoulder to WFL to participate in shopping

activities.

Patient will be able to independently don and doff

her bra. Patient will increase functional mobility (bed,

toilet, tub transfers) from CG to independence.

Patient will improve from mod to CG in

homemaking tasks.


17/25

Wii bowling.

Upgrade: Pt will stand for the entirety ofactivity.

Downgrade: Pt will sit on firm exercise ball.

Rationale: Pt will engage in Wii bowlinggame as she has previously expressedinterest in the sport Trunk Control

Posterior pelvic tilt

Grip strength

Fatigue

Increase L UE ROM


18/25

Pt and therapist will go on a shopping outing topts favorite store. Pt will have to try on a shirt,bra, and her choice of bottoms to purchase for abirthday outfit.

Upgrade: Pt may try on multiple outfits as wellas accessorize (i.e. earrings).

Downgrade: Pt will only need to try on a bra toavoid fatigue.

Rationale: Work on pinches (tip to tip & lateral) for jewelry and

buttons, snaps etc. UE strength and ROM

UE & LE dressing

Endurance


19/25

Pt. will participate in a scrapbooking activity, (squeezing

the glue, holding paper, removing/placing stickers). She willmake a collage of photos and decorate to place in herscrapbook.

Upgrade: Doing scrapbooking while sitting on the firm

exercise ball, (instead of chair), to work on posture andposterior pelvic tilt. Using thinner writing materials (pensinstead of markers).

Downgrade: Use thicker stickers, (foam, etc.), or rub on.Use glue stick instead of squeeze tube glue.

Rationale: decrease hand weakness

increase fine motor skills (pinch strengths)

posterior pelvic tilt/trunk control

endurance


20/25

Pt. will participate in aquatic therapythrough swimming and using water weights.

Upgrade: Increase the weight resistance,increase number of repetitions for each

exercise, exercise in a deeper depth of poolDowngrade: Decrease weight resistance,

decrease number of repetitions for eachexercise, participate in shallower end of pool

Rationale: improve left UE ROM

Endurance

UE strength


21/25

Pt will make meal of grilled cheese and tomatosoup. She will need to manipulate a triangle canopener and demonstrate kitchen safety whenworking with the stove.

Upgrade: Therapist will not provide any physicalassistance (i.e. opening cupboards, supplies,etc.)

Downgrade: Therapist will assist in activity bylaying out the ingredients, loosening jar, andstarting can opening process.

Rationale: Increase grip strength

Moving from max assist to min assist incooking/homemaking skills

Increase AROM of shoulder


22/25

Pt will use an arm bike as well as work withtheraputty.

Upgrade: Pt will need to increase amount oftime on arm bike and use a higher resistive

theraputty. Downgrade: Pt will decrease amount of time on

arm bike and use a lower resistive theraputty.

Rationale:

Increase trunk control Increase fine motor skills

Increase arm strength

These are needed to increase her participation in theleisure activity of being able to play a 3 minute song onthe piano.


23/25

Activity: Patient will sit upright on an exercise ball while

reaching only with her left hand for differently weighted

canned goods on a low-level shelving unit and placing them

on a countertop.

Upgrade: Shelves placed at various heights/reaching for

objects placed in multiple locations (i.e. fridge,

cupboard)/patient completes activity in standing.

Downgrade: Patient can be seated on a stationary chair,

decreasing the number of shelves, decreasing the number

of objects patient must reach, decreasing the distance

between the objects on the shelves

Rationale: Increasing L UE AROM, strength, coordination,grip strength, trunk control and balance, depth perception


24/25

Biomechanical Model: focus on balance,

strength, ROM, endurance

Model Of Human Occupation: volition-values,

interests; habituation-habits, roles (daughter,

student, sister); performance capacity(occupational participation, performance, and

skills)

Motor Control Model: to determine ways for pt to

create optimal performance in activitiesLifestyle Performance Model: examines

relationships of the pt to activity patterns to

reach needs and fulfillment


25/25

American Occupational Therapy Association. (2008). The referencemanual of the official documents of the occupational therapyassociation.(14th ed.). Bethesda, MD: The American Occupational TherapyAssociation.

Becks Depression Inventory. Retrieved fromhttp://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDe

pressionInventory1.pdf Berg Balance Test. Retrieved from

http://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdf

Internet Stroke Center. Berg Balance Scale. Retrieved fromhttp://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdf

Internet Stroke Center. Hamilton Rating Scale for Depression. Retrievedfrom http://www.strokecenter.org/wp-

content/uploads/2011/08/hamilton.pdf

Kielhofner, G. (2009). Conceptual Foundations of occupational therapypractice. (4th ed.) Philadelphia, PA: F.A. Davis Company

Radomski, M.V, Trombly, C.A. (2008). Occupational therapy for physicaldysfunction. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins.
http://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDepressionInventory1.pdfhttp://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDepressionInventory1.pdfhttp://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/hamilton.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/hamilton.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/hamilton.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/hamilton.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/hamilton.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdfhttp://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdfhttp://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdfhttp://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDepressionInventory1.pdfhttp://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDepressionInventory1.pdf

Bethany Case Study

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