1. Intern彭夢婷 Directed by Resident Dr. 陳泰宗 Directed by Attending Dr. 陳芝琪
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

2. 8H02A

3. General Data Chart No.: 2019784X Name: 王X豐 Age: 50 years old Sex: male
Marriage: Single
Occupation: Public servant
Race: Taiwanese

4. General Data Admission Date: 2009/8/2 Transfer Date: 2009/9/7
Hospitalization Days: 44 Days
Rehabilitation Days: Days
Premorbid Functional status: well
Premorbid ADL: independent

5. Major Diagnosis: Traumatic, closed head injury,
complicated with bilateral SDH of hemisphere sulci and right frontal ICH,
complicated with brain edema with left midline shift
Status post
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

8. Major diagnosis
Organic brain syndrome, presented with personality and behavioral changes
Intermittent disorientation
Self-talking
Restless behavior
Easily hot temper
Agitation
Poor sleep, fair appetite

9. Underlying disease
Type II Diabetes Mellitus, newly-diagnosed, under oral hyperglycemic agents’ control
Essential hypertension, under fair medical control

10. Assessment (8/28 at NS ward)
Mental status
Glasgow Coma Scale: E4 Va M5
Language and Swallowing
Naming: poor
Comprehension: poor
Repetition: poor
Manner: poor
Validity: poor
Swallowing: no dysphasia
Intubation
No Foley tube, no NG tube, no tracheostomy

11. Assessment Brunnstrom's stage Muscle Power
upper extremities(P): IV (right) II (left)
upper extremities(D): IV (right) II (left)
lower extremities: IV (right) II (left)
Muscle Power
upper extremities(P): 4 (right) (left)
upper extremities(D): 4 (right) (left)
lower extremities: (right) (left)

12. Assessment Functional status Katz index of ADL ANS: Bladder ANS: Bowel
Rolling/ sitting/ standing: poor
Ambulation: unable
Katz index of ADL
Bathing/ dressing/ toileting/ transfer/ feeding/ continence: totally dependent
ANS: Bladder
Incontinence, on diaper
ANS: Bowel
Incontinence

13. Rehabilitation Planning
Physical therapy
Passive ROM
Stretching training
Endurance training
Ambulation training
Poor rehabilitation potential

14. Current Medication For essential hypertension For NIDDM
Valsartan 160mg BID
For NIDDM
Metformin 500mg 1# TID
Gliclazide 60mg 2# BID
Acarbose 50mg 1# TID
Sitagliptin 100mg 1# QD
For Organic brain syndrome
Quatiepine 25mg 3# IRRE

15. Assessment (9/7 at 5G ward)
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
UE(P): V II
UE(D): V II
LE : 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
Rancho Los Amigos scale
Cognitive Level V~VI

16. Assessment (9/14 at 5G ward)
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
Br. stage: Right Left
UE(P): VI IV
UE(D): VI IV
LE : 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
Rancho Los Amigos scale
Cognitive Level V~VI

17. Barthel index 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

18. Rehabilitation Goal Goal: Cognition status Goal: Functional status
Improve cognitive function
Goal: Functional status
Improve the ability of standing and ambulation
Goal: ADL
To achieve ADL partial dependent

19. Rehabilitation Plan Physical Therapy: Occupational therapy:
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:
Posture training
ADL training
Moving training
Preceptual and cognitive function training
U/E and L/E function training

20. Thanks for your attention