Sunday, May 9, 2010

Health Talk

Topic:

Osteoarthritis and Exercise prescription

Background:



Reasons for choosing this Topic:

It has become clear to us during our community outreach visits that there are numerous patients who have osteoarthritis and are not being managed appropriately. Most of the patients that we have treated do not know that they have osteoarthritis and have no idea what osteoarthritis is. To make matters worse, the patients are not adhering to their home exercise programs, which lead us to believe that they do not know the importance of exercise as a treatment option. We feel that it will be useful to treat patients as a group class when doing community outreach as there are a large number of patients who have osteoarthritis

Aims of the health talk:

To create awareness in the community about osteoarthritis and treatment options to manage this condition.

Objectives:

To educate patients in the community about osteoarthritis.

To explain the importance of adhering to an exercise program.

To explain the correct manner of performing exercises.

To Educate about the benefits of Physical Activity in the community.

Target population:

Patient in the following clinics suffering from osteoarthritis:

  • Mbhokota Clinic
  • Bungeni Clinic
  • Muwaweni
  • Mashamba
  • Wayeni

Ethical Considerations:

Permission was obtained from the nursing staff at each clinic of the above mentioned communities. After a thorough explanation regarding the health talk and procedures to be followed, consent forms were issued to each participant to gain permission to do the health talk and allow us to take photographs. All data will be kept confidential and will only be used for academic purposes.


Method:

Information leaflets were created in Venda and Shangaan.

A verbal presentation, using a translator, was given to educate the participants regarding osteoarthritis
A poster was created showing the exercise routine that should be followed by the patients. We also instructed a group exercise class and taught patients the correct manner of performing these exercises.


Leaflets

Evaluation of the health talk (Effectiveness):

A mini questionnaire was handed out before and after the health talk to see if patients had learnt anything from the talk.

Benefits:

The participants will have gained knowledge about OA and we hope that they will be in a position to effectively do self treatment and create community awareness with regards to OA. The clinicians at Elim, can use our exercise protocol for future community outreach projects.

Recommendations and advice:

Acknowledgements:

References:

Pictures:











Health Screening

Screening

Topic:

Compliance to Physiotherapy home programs in patients suffering from osteoarthritis.

Background:



Reasons for choosing the topic:

During our community outreach we came across numerous patients suffering from osteoarthritis. The Physiotherapy outreach programme only visits the respective clinics once a month and therefore we feel it is important to establish whether or not these patients are complaint to their home exercise programs.

Aim of the study:

To establish whether or not patients with osteoarthritis are compliant with their home exercise program.

Target Population:



Objectives:

To establish demographic data of the patients.

To determine the extent to which patients are compliant to their exercise programs.

To establish reasons for non-compiance.



Tools used:

A self-constructed questionnaire will be used.

Ethical Consideration:


Significance of the study:

Method:

A self-constructed questionnaire was developed in three languages namely: English, Venda and Shangaan. These questionnaires were handed out and completed by the participants at the above mentioned clinics. Microsoft Excel was used for data analysis.

Results:




Recommendations:

Acknowledgements:

References:

Saturday, May 8, 2010

Background to Elim Hospital.



                                     The Chapel



History


The Hospital was started by Dr. George Lienge, a Swiss Missionary, in 1899.
Elim was the first establishment to receive electricity north of pretoria, even before the town of Louis Trichardt.
It played a critical 'neutral' role in the war between the British and the then South African (boere) government and served both sides.
The is a Museum at the hospital that is a national heritage site that you can still view which contaans some of the original equipment and furniture of the first hospital staff of Elim Hospital. It is interesting to note that the Gyni ward is the actual original hospital and the old theatre is still there. It is currently still in use and one can see the lantern holdings in the walls of this ward.
For more information about the history of the area, it is recommended that you contact Mr Charles Leach, a history buff who still lives in Louis Trichardt and has written a book (Captain Eagle) about the historical events of this era.


Location of the Hospital

It is located in the Vhembe distict, Makhado Municipality, ward 28, 25km south east of Makhado (Louis Trichardt). It is a subtropical area north of Capricorn (S23.15310 degrees E30.05720 , if you have a GPS these coordinates may be helpful).

Epidemiology / Most prevalent diseases or conditions

Immuno-supressant (HIV & AIDS)
Gastroenteritis
Pneumonia
Tb
Hypertension
Cataract
Trauma
Diabetes mellitus
Cardiac Failure

Wednesday, May 5, 2010

Daily Diary week 4

Day 1 (Monday)

7:30 - 13:00

We worked on the health promotion translation and treated a few OPD patients.  Most health professional that we asked were unwilling to assist with translations but we found a few social workers who would be willing provided be bought them lunch.  So at lunch time we made our way to KFC across the road and bought them lunch.

13:00 - 14:00
Lunch

14:00 - 16:30

I had an appointment to see the Clinical Support Supervisor at the hospital (Mrs Vosloo) who was willing to give me an overview of Elim hospital. I felt the need to get a background of the hospital as it is historical and I walso wanted to know a few facts concerning how the hospital systems of Limpopo are managed. Please see Blog entry: Background of Elim Hopital.
I went to see my ward patients and was glad to see that my one patient had finally been tranferred to Polokwane hospital to undergo surgery for a displaced midshaft femur fracture.

Day 2 (Tuesday)

7:30 - 14:30

Today we spent the day visiting the following community clinics: Watervaal, Mbhokota,Nkhensani and Bungeni. We did health screening and a health talk at Mbhokota clinic and Bungeni clinic. This was a great succees and most patients really benefited from the talk and enjoyed the exercise programme that was given after the talk.
I saw a 3 year old child with clubfoot and took a video. Please see the blog titled Interestin findings and reflections.

Day 3 (wednesday)

7:30 - 13:00



My morning and early afternnon was spent  visiting a patient near Marseilles Clinic. Mr Matwiki, a social worker, Rosy, Jacomie and I all travelled to the patients home. Our aim (The Physio team) was to build stairs that were wide enough to allow the patient to move as safe as possible (using a walking frame) in and out of her room. We used sand , large bricks, a spade, a wheelbarrow and the little cement that was available at the patients home to create this temporary entrance.

Before


Before









     

7 wheelbarrow loads of sand, plenty of sweat & tired physio's, the final product.


Day 4 (Thursday - Final day of the block)

7:30 - 15:30

The day was spent doing community outreach. We visited the following clinics:

  • Muwaweni

  • Mashamba

  • Wayeni

  • Riverplaats
We conducted health talks and gace exercise classess for OA patients at Muwaweni, Mashamba & Wayeni. Riverplaats did not have enough patients do give a health talk, so the one or two patients were treated individually.


Thursday, April 29, 2010

Daily Diary - Week 3

Well this week is somewhat shorter due to the public holiday on Tuesday and because of this most of the clinicians at Elim only worked half day on Monday. Our supervisor was kind enough to give us monday off.

Day 1 (Wednesday)

7:30 - 10:00

We (Jacomie, Rosy and I) worked on our health screening which we plan to do tommorrow. We designed a questionnaire which needed to be translated to Venda and Shangaan, the two main languages spoken in most of the villages that we will visit during community outreach.
I visited my case report patient (Mrs Mnisi) in the ward. Unfortunetly she is in a bad state and has a glascow coma scale of 3/15. They are still unable to lower her BP (214/138mmHG) and I am not able to do much with my patient untill the BP has been lowered.

10:00 - 10:30

Breakfast

10:00 - 13:00

I visited my ward patients (new surgical Ward) and they seem to be progressing well. The male patient I'm treating will hopefully be going for surgery next friday at Polokwane (fingers-crossed). He already has a leg length discrepancy due to poor management (skin traction) of a midshaft of femur fracture. The goverment hospitals are fully booked and have a backlog of patients awaiting surgery. They simply manage the patient in bed until they get a chance to be operated on. This is unfortunate, as most patient develop complications such as leg length discrepancies, pressure sores, contractures and general body weakness. As physiotherapist we do have a role to play in preventing some of these complication given the current situation in primary and secondary hospitals, but unforunately there are way too many patients to see for the amount of physiotherapy staff as is the case at Elim hopital.

13:00 - 14:00

Lunch

14:00 - 16:30

I spent the rest of day treating outpatients at the physiotherapy department.


Day 2 (Thursday)

7:30 - 15:00

The day was spent visiting four rural clinics for the community outreach progam.
Mr Matswiki, Jacomie, Rosy, four other health professionals ( 1 OT, 1 Optomitrist, 1 Speech therapist and Dietitian) and I went to see the following clinics:
- Mashau
- de Hoop
- Kurhuleni
- Marseilles











There was some sort of mix up with the dates and most patients did not pitch at the clinics. We did screening at Marshau (only 2 patients) and plan to revisit the clinic next week.
At Marseilles one of the nurses present at the clinic asked us (the Physio's)to see a patient who lived nearby. The patient has an unknown pathology that we were unable to diagnose. She has extensive tissue damage which limits right knee extention and flexion. The patient is being neglected by her family and she does not get food on a regular bases. The family is unwilling to help her due to internal family conflicts. The room is cluttered and there is a large step at the entrance which restrict her from mobilising with her walking frame. Intervention needs to take place to help improve her situation and try resolve the matter. I hope to revisit the patient next week to help change her environment so that she can be more functionally independant.

Day 3 (Friday)

7:30 - 10:00

We worked on our health talk and are finding it difficult to find someone who will translate the information leaflet and exercise instructions to Venda and Shangaan. This is delaying us but we hope to complete the poster and leaflets before Tuesday next week.
I was fortunate enough to observe and assist with the strapping of a 1 day old baby who has talipes equinovarus (clubfoot). Please see My other post on Interesting findings and Reflections.

10:00 - 10:30

Breakfast

10:30 - 13:00

I spent the rest of the day treating patients in OPD.
A patient approached me demanding I give him a Disability Grant. The patient was extremely racist and potential Psychotic and it was a rather scary situation. Please see My blog on SWOT and SPAR Notes for more details.

Tuesday, April 27, 2010

Interesting Findings and Reflections

14 April 2010

Today I was fortunate enough to treat a patient who has Bells Palsy. I had not seen this condition before and I decided to readup on Bells Palsy to gain a better understanding of the condition.

Bells palsy:
Studies have shown that men and women are equally affected by Bells Palsy and there is a higher incidence in pregnant women.
The main cause of Bells Palsy are the Herpes Simplex viruses: Herpes Simplex virus type 1 and Herpes Zoster virus (This presents with more severe symptoms).

Symptoms are:
- Decreased production of tears
- Altered taste Otalgia (earache)
- Fascial / Retroauricular pain Fascial Paresis - Patients usually think that they have had a stroke or have a tumour).
- Bells Phenomenon - The upward diversion of the eye when attempting to close the lid (incomplete closure) is a obvious clinical feature of Bells Palsy.

It is interesting to note that Bells Palsy causes periperal lower motor neurone palsy which presents as follows:
Unilateral impaired movement of the fascial and platysma muscles, drooping of the brow and the corner of the mouth and impaired closure of the eye and mouth. A central upper motor neuron lesion as seen in stroke, causes weakness of the lower face only. This is a useful way of differentiating the two conditions.

Treatment of Bells Palsy:
- Medical intervention should begin immediately to stop viral replication which results in inflammation of the fascial nerve (Reversible neuropraxia). Medication includes - Antivirals such asaciclovir and coricosteriods (prednisone).
- Psychological support Eye care - To protect the cornea from drying and gettin abrasions (Eye drops should be applied hourly).
- Surgery (middle fossa craniotomy) involves decompression of the fascial nerve. The operation has several risks such as seizures, deafness, leakage of cerebral spinal fluid and fascial nerve damage and this is why surgical intervention is not routinely done.
- Physiotherapy - Massage, fascial exercises and mime therapy have been useful treatment options. TENS (transcutaneous electrical stimulation) has uncertaian effects.

Reference: N Julian Holland, Graeme M Weiner. Clinical review: Recent developments in Bell’s palsy. BMJ 2004;329


30 April 2010

Today I observed the physiotherapy management of a 1 day old baby with Talipes Equinovarus (Clubfoot). I got consent from the mother to take photo's of the baby's feet before and after strapping. The baby has unilateral clubfoot of her left foot.





Talipes Equinovarus seems to be a common condition seen at Elim Hopital. I feel that the management of clubfoot is poor and ineffective and I've decided to read-up on this condition to get an overview and find out about other management options.

There are 4 variations of clubfoot:
1) Talipes Varus - foot turned inwards resembling the letter J (Inversion and adduction).
2) Talipes Valgus - foot turned outwardly resembling the letter L (Eversion and Abduction).
3) Talipes Equines - Foot points downwards (Plantarflexion).
4) Talipes Calcaneus - Foot points upwards (Dorsiflexion).

* Clubfoot usually resembles a combination of the 4 variants. As the name indicates (Talipes Equinovarus)the foot deformity is commonly in Inversion, Adduction and Plantarflexion (Seen in above Picture).

The causes of clubfoot is speculative. Some authors mention abnormal intrauterine positioning of the fetus and there is evidence of genetic predispostion for Talipes equinovarus.

Surgical treatment of clubfoot seems to have many risks, complications and poorer outcomes. Patients develop weak, stiff and scarred feet. Studies Have revealed high success rates for the Ponseti Method (92 - 98%). The Ponseti method is a conservative treatment method that was developed by Ignacio V. Ponseti in the 1940's and was based on his observations in the clinic nad operation room. The goal of the Ponseti method is to impose simultaneous supination and abduction of the foot. There are 2 phases to this technique:

1) Treatment phase

This involves gentle manipulation of the foot and serial casting. Each cast holds the foot in the correct postion so that the foot is gradually 're-shaped'. Most infants will require a percutaneous tenotomy after the last cast (Usually 5- 6 cast are done, 1 cast per week) to gain adequate lenghtening of the archilles tendon.

2) Maintenance phase

An orthosis is used to prevent relapse of the deformity. A denis-browne splint is usually used which the infant wears for 23 hours a day for 3 - 4 months an then at night (12 hours) for the next 3 years.

I feel that the strapping seen in the above pictures is not effective (poorly done) and other medical intervention should be done. It would be interesting to know the long term outcomes of these patients and whether or not the Ponseti method could be implemented at Elim hospital. This may not be feasible due to the lack of resources available at district level but I do think that it would be very benificial and have high success rates in this community.

Reference: R Kamper, K Binks, M Dunkley, C Coats. Multidisciplinary management of clubfoot using the Ponseti method in a district general hopsital setting. Journal of Child Orthopaedics, 2008;2: 463-467 RA Agrawal, MS Suresh, R Agrawal. Treatment of congenital clubfoot with Ponseti method. Indian Journal of Orthopaedics, 2005; 39(4):244-247

4 May 2010

During my community outreach vistits, I came across a 3 year old Child with Clubfoot. According to the mother, the child has orthotic shoes that she is suppose to wear but is unwilling to wear them due to the fact that other children laugh at her when she puts them on. I am not sure what sort of medical management can be done for her at this stage but this goes to show, in my opinion, that Elim is not offering appropriate treatment for patients with clubfoot.
Please see attached video to observe how clubfoot has affected the childs gait.

Monday, April 19, 2010

Swot and Spar notes

Week 1 (12 - 16 April 2010)

Strengths

I have recently completed my OPD block at Kalafong Hospital where I gained a lot of experience in assessing and treating patient's with back problems. I am therefore finding it relatively easy to treat the physiotherapy out-patients (OPD) at Elim hospital as it seems that the majority of the patients present with back problems.

Weaknessess

I am finding it difficult to blog. There have been occasions when I have lost my saved blog posts as the work that I type sometimes fails to post or save properly as it should. This it exremely frustation and time wasting as I end up having start all over again. I am unsure as to what is causing the problem but I am now trying to back my work up on microsoft word documents and will save as often as possible.

I have still a lot to learn about the different cultural traditions and beliefs which is still new to me. I may not be as sensitive or understanding to my patients ways when assessing and treating certain patients as I should be (I am still learning).

Opportunities

I have a lot of freedom to learn especially during the home visits in the community and during the outreach programs. I have to organise projects by myself with minimal assistance from the staff who are open to suggestions. I am building on my managerial skills and am learning to priorities according to what I feel it most important.


Threats

We have transport limitations at the hospital as the transport department is reluctant to allow us (MEDUNSA students) to make more home visits. We therefore have to arrange our own transport and go to the Watervaal community by ourselves which is not ideal.
There is also a transport problem that may prevent us (MEDUNSA students) from going with during the weekly community outreach program.

The language barrier is limiting me from conducting thorough assessments with certain non-english speaking patients (As many as 40 % of my patients did not speak english). The physiotherapist and physiotherapy assistants are seldomly available to assist with translation. I therefore, base my treatment on objective findings alone and cannot ,unfortunetely, perform extensive assessments on certain patients.

Spar notes (22 April 2010)

Situation

I went to visit a patient at her home in the Watervaal area. I have been seeing her since last week (13/04/2010) and had planned to begin assisted crutch walking and balance training for todays treatment session. I soon was informed that my patient had collapsed earlier and I realised that she had sustained another stroke. The patient has a history of uncontrolled hypertention. On my previous visit, I had advised the family to see to it that the patient received hypertensive medication as soon as possible to prevent her having another stroke.

People

As I arrived I came across two new faces which I later identified as the patients eldest daughter (Dorothy) and son-in-law. The house help, eldest granddaughter (18yr old)and the patient's younger daughter (breadwinner) were all present when I arrived at the house. Dorothy and her husband had arrived after receiving a phone call informing them of the patients condition.

Activity

The patient was not communicating as she normally does and was drooling. She seemed confused and later broke down saying that she just wanted to die. Dorothy was releived to see me and hoped I could assist her. We decided to take the patient to the local clinic (Watervaal) to get further management. I assisted the family in tranfering the patient to their car and accompanied them to the clinic. At the Watervaal clinic I spoke to the nurse in charge and I explained the situation and she then told us to rather go see a doctor at Elim Hopital. We then travelled to Elim hospital and took her to casualty. I tried to comfort Dorothy and the patient and I explained to them what CVA is and how it comes about. By this time, the patient was in a daze and was disorientated. She could not assist me when a nurse and I tranferred her from the car into the wheelchair. Once I finally got the patient to the relevant doctor, I informed the doctor of her medical history. The nurses took her blood pressure which was 221/104. After further assessment the doctor then admitted the patient. I later went to see her and it seemed that she was sedated and could not recognise me.

Reaction:

I feel that the CVA could have been prevented. The patient and her family were well informed about the need to get her anti-hypertensive medication to prevent just such a situation. I feel that nothing was done due to the reluctancy by her younger daughter (the breadwinner of the household) to take responsibility to help her mother. I was later informed by Dorothy that the younger daughter had a pyschiatric history (Bipolar disorder) which may explain the loss of interest in her mothers condition. Although it was sad to see my patient go through such an ordeal, I felt I learnt a lot from the situation and will be better prepared for the procedures to be followed if such a situation should happen again. I saw "another side to stroke". We as physiotherpist are usually only involved in the rehabilitaion stages and we dont get to see the actual attack happening. I will follow up on the patient and reassess her in the wards and take it from there.

Spar Notes (30 April 2010)

Situation

I was sitting in the physiotherapy department when a patient approached me and demanded that I give him a disabilty grant.

People

Jacomie, Rosy and I were alone in the department as the other permanent staff were at a departmental function. Fortunetly Mr Matswiki arrived later to handle the matter.


Activity

The patient was explaining that he had being given a temporary disabilty grant (6 months) which was now expired and he was referred by a doctor for a physiotherapy assessment before another grant could be issued. He had a injury to the left arm (possibly a fracture) that had complicated and from what I could see he seemed to have a flexor contracture of the wrist. He made racial remarks at me and Jacomie and blamed us for all the trouble he had to go through as each health professional kept on referring him to different hospital or department etc. He somehow expected us not to give him the grant and did not want us to assess him (which is procedure) and would not let us view the documentation that brought with incase we stamped or refused to give him the grant. Mr Matswiki had arrived at the department and soon took over the matter. The patient raised his voice and was extremely aggressive and showed violent body language. He said to us that his child was starving and he could not provide food on the table because he could not work. I did not understand what they further discussed because the were talking in Venda. I do not know what the final outcome of the matter was but was relieved to see the patient go.

Reaction

I remained calm throughout the encounter and I ignored the patients comments. When Mr Matswiki arrived I took my tazer out of my bag as a precautionary measure. I felt that the situation would have escalated if my Matswiki had not arrived and I beleive the patient may even have become violent. Just from a general observation I do not beleive that the patient was so functionally impaired to deserve a disabilty grant and I think he had been refused a grant at other hospitals prior to visiting Elim.
This incident just highlights the numerous socio-economic and political problems in south africa. The disabilty grant is so often the only income for some patients and without it you are take away their lifeline. It makes the job of health professionals particularly challenging as it is our goal to improve the patients condition which may have negative impact on the patient because they will no longer have a source of income.

Daily Dairy - Week 2

Week 2 (19 - 23 April 2010)

Day 1

7:30 - 10:00

I assessed and treated two outpatients. I'm still struggling with the language barrier and base my assessments on my findings of the physical examination and palpation. The physiotherapists and physiotherapy assistants are not always available to assist as a translator.

We (Rosy, Jocomie and I) made arrangements with the chief physiotherapist at Elim and the transport department to accompany others during the community outreach program tommorrow. There may not be space in the car for all three of us to go which is unfortunate as I feel we will benefit greatly from this experience

10:00 - 10:30

Breakfast

10:30 - 13:00

I assessed and treated more outpatients.

13:00 - 14:00

Lunch

14:00 - 16:30

I went to see my ward patients (new surgical ward) and made sure they were compliant to there exercise program (previously given). My one patient has a large leg length discrepancy due to poor management (skin traction) of a midshaft femur fracture. He is currently awaiting surgery at Polokwane.

I was fortunate enough to observe and assist foot strapping of a 3 day old baby who I beleive has signs of hypermobility syndrome. The Occupational therapists (OT)could apparently do nothing to assist. I am glad that early intervention is taking place but I feel that strapping the child once a week is ineffective and I still hope that the OT's may help and supply the baby with a more permanent splint.

I further spent my day assessing and treating outpatient's.

Day 2

7:30 - 13:00

I waited for the dietician to call us so that we could leave together to do community outreach. We (Rosy, Jacomie and I) went to three clinics, namely; Vleifontein, Nthabalala and Manyima accompanying a dietician, speech therapist, occupatienal therapist, optomotrist and one of the physiotherapy assistants.
All three of us treated each patient together as there was insufficient space to allow us to do individual treatments. I thought that the treatments were not as effective as they could be due a shortage of resources. We had a total of ten patients to see, of which eight had OA and two had CVA. I can now see why the previous Medunsa students felt the need to give health talks and exercise programs for OA. I feel that we need to continue their efforts as it can greatly benefit the community.

13:00 - 14:00

Lunch

14:00 - 16:30

I went to see my two ward patients in the new surgical ward. We had received another patient referral. I approached the patient to begin my assessment of her and she refused my help and was rather rude. I was not sure as to why she did not want to get physiotherapy as I could not understand a word that she was saying. I later found out that she was a traditional healer. So I proceeded to write in her file that she was unco-operative and refused treatment, when she became upset and tried to take the file away. It was a funny situation. (see spar notes still to be blogged). Jacomie is currently treating the patient.

When we got back to the department we arranged to speak to Mrs Louw (chief physiotherapist) concerning the history of the hospital as we thought it would be interesting to have background knowledge of the hospital. She tried to answer some of our questions and referred us to relevant people who could be more helpful in answering some of our questions. I will add this to my blog as soon as I have completed the task.

Day 3

7:30 - 10:00

I spent the day treating outpatients at the physiotherapy department.
I saw a few CP children as there was a cp clinic today. I've realised that I lack experience when treating CP children. Fortunately Mrs Louw was willing to help me with any problems that I encountered. I assisted her with the CP patients that came for the CP clinic today. This was rather benificial and I learnt a lot in the process. I learnt that there is a problem with the way the interdisciplinary team operates. Each patient has to go to each of the relevant departments and information is not shared appropiately.

10:00 - 10:30

Breakfast

10:30 - 13:00

I saw more OPD patients.

13:00 - 16:30

I went to see our my ward patients again and encounted a problem with one of my patients. He was suppose to go to Polokwane and did not go apparently due to transport problems. He was very dicouraged and asked me to find out if it would be possible to tranfer him to another hospital as he felt that it would take long to get another chance to get proper treatment. I told him I'd get back to him and speak to the relevant persons to try and help his situation. It is his right to have access to another hospital and I feel that he will have a permanant deformity if he is not operated on soon.

Day 4

7:30 - 10:00

Rosy, Jacomie and I worked on our health talk. We managed to plan the health talk and began developing a questionnaire for our screening.

10:30 - 10:30

Breakfast

10:30 - 13:00

We then, using our own transport, went to visit our home patients (Watervaal community). My patient (Used in the case report) had another CVA two hours prior to my arrival. Please see Spar notes for further details (22/04/2010).

13:00 - 14:00

Lunch

14:00 - 16:30

I saw my ward patients again who seem to be compliant with their exercise program.

After seeing my ward patients I went to see my home visit patient who was admitted to the Gynaecology ward (shortage of beds).She was sedated and did not recognise me. I will see her tommorrow to see how she is doing.

Day 5

7:30 - 10:00

I spent the morning working on our health talk

10:00 - 10:30

Breakfast

10:30 - 13:00

I visited my ward patients and assisted Jacomie with an elderly patient that she was seen who had an above knee amputation (AKA).
He has pressure sores on his left buttock and had general body weakness which I beleive has developed as a complication of long bed rest due to delayed surgical intervention. This is unfortunetly the situation at Elim hospital.

Sunday, April 18, 2010

Case Report - Home Visit



Patient's Name: Annetjie Mnisi
Age: 76 yrs
Diagnosis: Left CVA
Occupation: Pensioner
Date of evaluation:13th and 15th April 2010
Name of Supervisor: Mr T Matswiki
Name of Student: Corrine Sheppard

Subjective evaluation:

Present Medical History:

The patient reported that she was sleeping and when she awoke the next morning, she was unable to get out of bed due to paralysis of the right upper limb and severe weakness of her right lower limb(The incident occured mid November 2009).Her family took her to Elim hospital where she was admitted for a month.

Past Medical History:

The patient has not been to a hospital for any serious medical treatment prior to the latest incident. She does however have a long history of hypertension.

Lifestyle and Socio-economic History:

The patient is living with her daughter, son-in-law, and three grandchildren in a four bedroom brick house in the watervaal community (Approximately 12 km from Elim hospital). Her daughter is a police officer and is the breadwinner of the household.
The patient has three caregivers namely the house help who comes in 5 days a week and her two grandchildren (A 18yrs old girl and a 13yrs old boy).
The patient has no history of smoking or drinking alcohol. The patient use to enjoy going to church, shopping and visiting her other daughters who live in the nearby communities. She is no longer able to do these activities due to her functional limitations.

Medication:

She is currently not taking any medication. This is a concern as she is not managing her hypertension and has a chance of having another stroke.

Home Environment:

Internal

The toilet and bath tub is inaccessible to the patient due the lack of space.The tiles in the lounge and passageway are slippery which is a potential hazard to the patient as this may lead to her falling.
The basin in the bathroom is unstable and is also a hazard to the patient as she tends to lean on it when she enters the bathroom. There is a mat on the one side of the patients bed and the patient struggles to get passed the mat(Hazard). The patient is currently using a bucket as a toilet when she needs to go at night. This is ineffective and she reports that it is difficult and she struggles.








External

There are two large steps at the front (kitchen) entrance of the house. The washing line is also in the way as it runs near the front entrance. The garden is uneven in certain places especially at the front entrance. The garden furniture will block the way and may need to be moved at a later stage. The back door has two small step and there an even cemented pathway. This is the exit point of choice.







Activities of daily living:

The patient wakes up in the morning and needs assistance when getting dressed. She is then helped to the lounged (supported walking) where she spends most her day watching television. She requires assistance to go to the toilet (supported walking) and receives food and cooldrink from the house help.She unfortunetly does not go outside and sit in the sun or do any other exercises during the day. At night she requires help to get in and out of the bath and uses a wash bucket for toilet relief during the night.
The Barthel index was used to assess her functional status (Still to be attached)

Patient's Expectations:

My patient wants to be able to walk independently.


Caregiver's Expectations:

They want the patient to be able walk indepentently and to grab objects with both hands. they want her to be more functional so that they don't have to help her with so many activities of daily living.

Caregiver's Role:

The caregivers help her to get in and out of bed. They help her dress, bath, provide her with food and assist her in getting to the toilet in the day. She is very dependant on them and needs assistance in most activities of daily living (ADL).

Objective Evaluation

Initial Observation:

The patient was seated in the TV room in a forward flexed position (sloughed in her chair. The patient seemed quite depressed.

Communication:

The patient was able to communicate with me fairly well speaking english. Her home language is Shangaan. She has no apparent speech impairment.

Posture:

The right arm was in an adducted postion with her forearm flexed slightly on her lap in a fully pronated position. The fingers were all flexed in a fist. Her right shoulder is depressed and the scapula is protracred and externally rotated. The patients right shoulder is subluxed (sulcus sign present) and the patient reported that she is experiencing shoulder pain. The trunk was in forward flexion and rotated to the left. The right foot is excessive plantarflexion.

Muscle tone:

The patient has increased muscle tone on the right elbow extensors (Grade 2 modified Ashworth scale) and a slight increase in muscle tone of the right knee flexors (i.e. hamstrings - Grade 1 modified Ashworth scale). The right scapula has increased tone (grade 2 Mod Ashworth) when protractin the scapula.

Passive ROM:

The patient has a right elbow extension contracture.
The right foot has 12 degrees of dorsiflexion (Firm end feel - shortening of the Tibialis anterior).

Active Rom:

The patient has paralysis of the right wrist and hand. The forearm flexors are extremely weak (Grade 2- Oxford grading) and only able to acvtively flex her forearm 10 dergrees in the inner range (ROM 15 - 25 - 150).

Co-ordination testing:

The patients was able to perform the finger-to-nose and heel-to-shin test without difficulty. No signs of dysdiadochokinesia (tested on the unaffected upper limb).

Proprioception:

She has decreased proprioception in the left and right hips. The prioprioception of the knees is good.

Balance:

In sitting the patient has good static balance but dynamic balance is decrease as she struggles to reach for objects on the affected side. Her static and dynamic balance in standing is poor and she is unable to stand upright without support.
A Berg balance scale has been used to assess her balance status (still to be attached).

Berg balance scale:
Item Description Score (0 -4)

Sitting to standing 1
Standing unsupported 0
Sitting unsupported 4
Standing to sitting 1
Transfers 1
Standing with eyes closed 0
Standing with feet together 0
Reaching forward with outstretched arm 0
Retrieving object on floor 0
Turning to look behind 0
Turning 360 degrees 0
Placing alternate foot on stool 0
Standing with one foot in front 0
Standing on one foot 0

Total 7 / 56
Conclusion of findings:
The patient has poor balance which has contributed to poor functional independancy.
< 20 points indicates that the patient is wheelchair bound
Functional Assessment:

The Barthel Index:

Activity Score

Feeding 5
Bathing 0
Grooming 5
Dressing 0
Bowels 10
Bladder 10
Toilet Use 5
Tranfers 10
Mobility 10
Stairs 0

Total 55 / 100

Conclusion of findings:

Gross and Fine motor skills:

The patients is unable to use her right hand (Dominant hand) and has to now use the left hand to perform ADL. She is learning how to do tasks such as looseninng buttons , drinking from a cup and grasping objects with her left hand. Her gross and fine motor control with her left hand is reasonable but there is room for improvement.


Hearing and Vision:

This is good and both are intact. She is able to localise sound around both ears and can follow objects in all for quadrants of the visual field.

Reflexes:

She has an increased right knee jerk and a slightly decreased left knee jerk.






Please note: Still to be completed