History

Pre-1992
1992
1993
1994
1995-96
1997
1998
1999

Home

Assessment
(Simonson - October 20, 1997)

Physical/Occupational Therapy
Discharge Summary

Therapist Name:  Jeanine Helberg, OTS / C. Heerema, OTR
Physician Name:  Simonson
Date: 10/20/97
Diagnosis relevant to physical medicine and rehabilitation: Spastic Quadriparesis, ataxia, dysarthria, dysphagia, and decreased muscle strength of unknown etiology.

Current goals, therapy orders, equipment, status and recommended follow-up and/or comments:

Patient is a 32 year old female with spastic quadriparesis, ataxia, dysarthria, dysphagia, and decreased muscle strength of unknown etiology.  Past Medical History:  Patient has a history of 5 year progressive course of neurologic decline, delusions, paranois, dysarthria, aphasia, vertical gaze paresis, and gait disorder.  Areas Addressed by OT / OT Orders:  Activities of daily living evaluation, training, and equipment as needed.  Active range of motion to extremities with prolonged stretch for decreased spasticity.  Program:  Patient was seen x4 by OT for 30 minute sessions.  Social History / Home Environment:  Prior to admission, patient was living in a 1 story walk in house with husband and three year old daughter in Clinton, Mississippi.  Prior Functional Status: Per patient and mother, patient was walking around house independently, but falling a lot.  Patient was independent in all activities of daily living however, mother lived with her for awhile to assist in childcare.  Mother used stove secondary to patient's decreased short term memory and safety.  Patient used a grab bar in tub only.  Patient received OT/PT home health care.  Therapists thought patient would do better in home environment secondary to decreased attention span.  Status changes daily both physically and cognitively according to parents and therapists.  Current Goals:  Maximize safety and independence in functional activities/self cares.  Increase upper extremity active range of motion, strength, and coordination to improve functional skills.  Current Status:  Activities of Daily Living:  Feeding: Patient has had a peg tube since Aug. 12 secondary to dysphagia.  Family and patient state they would like a swallow evaluation completed as soon as possible as patient demonstrates increased oral control.  Hygiene/Grooming:  Independent with verbal cues as per family.  Bathing:  Minimal to moderate assist with bed bath as per family.  Dressing:  Minimal to moderate assist as per family.  Toileting:  Transfers with moderate assist, patient presently has a catheter.  Upper Extremity Function:  Active range of motion not formally assessed but appear within functional limits.  Passive range of motion within functional limits.  Coordination is maximally impaired bilaterally, results as follows.  Box and blocks:  Right hand = 14 blocks per minute; N = 85.2 per minute.  Left hand = 17 blocks per minute; N = 80.2 per minute.  Nine hole Peg:  Right Hand Avg. = 2 min. 40 sec.  N = 16.3 sec.,  Left Hand Avg. = 3 min. 27 sec.  N = 17.8 sec.  Patient denies any pain or loss of sensation at this time.  Bilateral upper extremities appear to have increased tone in all directions of movement.  Cognition:  Patient appears to have a decreased attention span.  Per family, patient has difficulty with short term memory and comprehension at times (for example pulls at catheter).  Recommendations:  Recommend patient be seen 2-3x/day for 30-45 min. sessions to continue assessment and treatment of activities of daily living and upper extremity function.  Recommend patient be seen as soon as possible for swallow evaluation as oral motor control has improved.  Recommend cognitive assessment to ensure patient safety.