复健科案例联合讨论会.ppt

健科案合討會,Intern彭夢婷DirectedbyResidentDr.陳泰宗DirectedbyAttendingDr.陳芝琪,8H02A,GeneralData,ChartNo.:2019784XName:王X豐Age:50yearsoldSex:maleMarriage:SingleOccupation:PublicservantRace:Taiwanese,GeneralData,AdmissionDate:2009/8/2TransferDate:2009/9/7HospitalizationDays:44DaysRehabilitationDays:11DaysPremorbidFunctionalstatus:wellPremorbidADL:independent,MajorDiagnosis:,Traumatic,closedheadinjury,complicatedwithbilateralSDHofhemispheresulciandrightfrontalICH,complicatedwithbrainedemawithleftmidlineshiftStatuspostICPmonitorimplantationon2009/08/03RightF-T-Pcraniectomyon2009/08/04RightfrontalandtemporalpartiallobectomytoremoveICHon08/04,Majordiagnosis,Organicbrainsyndrome,presentedwithpersonalityandbehavioralchangesIntermittentdisorientationSelf-talkingRestlessbehaviorEasilyhottemperAgitationPoorsleep,fairappetite,Underlyingdisease,TypeIIDiabetesMellitus,newly-diagnosed,underoralhyperglycemicagentscontrolEssentialhypertension,underfairmedicalcontrol,Assessment(8/28atNSward),MentalstatusGlasgowComaScale:E4VaM5LanguageandSwallowingNaming:poorComprehension:poorRepetition:poorManner:poorValidity:poorSwallowing:nodysphasiaIntubationNoFoleytube,noNGtube,notracheostomy,Assessment,Brunnstromsstageupperextremities(P):IV(right)II(left)upperextremities(D):IV(right)II(left)lowerextremities:IV(right)II(left)MusclePowerupperextremities(P):4(right)2(left)upperextremities(D):4(right)2(left)lowerextremities:4(right)2(left),Assessment,FunctionalstatusRolling/sitting/standing:poorAmbulation:unableKatzindexofADLBathing/dressing/toileting/transfer/feeding/continence:totallydependentANS:BladderIncontinence,ondiaperANS:BowelIncontinence,RehabilitationPlanning,PhysicaltherapyPassiveROMStretchingtrainingEndurancetrainingAmbulationtrainingPoorrehabilitationpotential,CurrentMedication,ForessentialhypertensionValsartan160mgBIDForNIDDMMetformin500mg1#TIDGliclazide60mg2#BIDAcarbose50mg1#TIDSitagliptin100mg1#QDForOrganicbrainsyndromeQuatiepine25mg3#IRRE,Assessment(9/7at5Gward),Urine/stool:incontinence/incontinence,ondiaperNoNGtube,noFoleytube,notracheostomySwallowing:nodysphagiaSpeech:milddysarthriaComprehension:poorfluency/repetition/naming:unableBr.stage:RightLeftUE(P):VIIUE(D):VIILE:VIIFunctionalstatus:rolling:good;sitting:fair;standing:poor;walking:unableKatzindexofADL:bathing:D;dressing:A;toileting:D;transfer:D;feeding:A,RanchoLosAmigosscaleCognitiveLevelVVI,Assessment(9/14at5Gward),Urine/stool:continence/continenceNoNGtube,noFoleytube,notracheostomySwallowing:nodysphagiaSpeech:nodysarthriaFaircomprehensionandspontaneousspeechPoorfluency/repetition/namingpressuresore:nilBr.stage:RightLeftUE(P):VIIVUE(D):VIIVLE:VIIIIFunctionalstatus:rolling:good;sitting:fair;standing:poor;walking:poorKatzindexofADL:bathing:A;dressing:I;toileting:A;transfer:A;feeding:I,RanchoLosAmigosscaleCognitiveLevelVVI,Barthelindex,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。總分：六十分,RehabilitationGoal,Goal:CognitionstatusImprovecognitivefunctionGoal:FunctionalstatusImprovetheabilityofstandingandambulationGoal:ADLToachieveADLpartialdependent,RehabilitationPlan,PhysicalTherapy: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