Patient Information: Age: 38 y/o bf
Diagnosis Initial onset: Pt d/c from hospital in May after being treated for UTI. Pt returned to ER on May 27 with c/o progressive weakness and tingling in bilateral LEs and pt unable to stand. Pt was admitted and eventually diagnosed with Guillain-Barré. Pt was placed on ventilator during acute stay. Pt was also diagnosed with left lower lobe pneumonia during hospitalization.
Past Medical History: HTN, hysterectomy, peptic ulcer disease.
Social History: Pt had lived independently, but plans to live with parents after d/c. Pt has one step to enter home. Pt is planning on living on first level of home.
Physical Therapy Services: Pt was seen 2-3 times a day for the following services: LE stretching, facilitation and strengthening, bed mobility, and standing balance training, endurance training, gait training, occasional massage and/or hot packs for left hip pain, and pt and family education.
Date of Discharge: 9/18/96
Subjective: Pt would occasionally c/o of pain in her left hip with strenuous exercise. PT noted much muscle guarding and tightness. Pain was relieved with deep massage and hot packs. Pt also occasionally c/o pain in bilateral feet. Pt and PT attributed pain to nerve regeneration secondary to pain was mostly muscle spasms and deep pain. PT and physician also suggested orthotics for pt's shoes to assist with ankle control and possibly to decrease pain.
Orientation: Alert and oriented X4.
Posture: No significant abnormalities noted in sitting or static standing. See gait for dynamic standing assessment.
Range of Motion: Bilateral LEs WFL active and passive ROM with tightness noted in bilateral ankles with ankle dorsiflexion to neutral with knee extension and prone knee bends at 62 degrees on right and 72 degrees on left with tightness noted in quadriceps.
Proprioception: Unable to formally assess, but with gait appears diminished in bilateral feet and ankles with left showing greater deficits than right.
Tone: No abnormal tone noted.
Sensation: Pt reported occasional numbness and/or pain in bilateral feet.
|Standing||With walker: Fair+
Without walker: Fair
|With walker: Fair+|
Without walker: Poor
Endurance: Fair: pt tolerated 30-45 minute PT session with rest breaks and encouragement at times.
|Sitting to supine||Independent|
|Supine to sitting||Independent|
Transfer Preparation: Independent
|Mat||Stand pivot independent|
|Bed||Stand pivot independent|
|Floor||PT and pt discussed technique for getting up from floor. Pt did not attempt secondary to LE weakness and pain.|
|Car||Stand pivot with supervision|
|Stairs||Pt is able to negotiate 6 inch curb with walker with CGA for safety. Pt has been working on increasing quadriceps strengthening by controlling stepping up and down 6 inch step with hand rails with min assist and max verbal cues.|
|One foot standing||Not addressed.|
|Walking backwards||Pt was able to walk backwards (2-5 feet) to wheelchair with wheeled walker with CGA and good knee control.|
Wheelchair Propulsion: Independent on level terrain.
Gait: Pt ambulating with wheeled walker 150 feet with SBA. Pt ambulating 1-2 times per session due to endurance and ankle pain. Pt demonstrates following gait deviations: bilateral foot drop, poor heel-contact, decreased cadence, and decreased step length. With fatigue all gait deviations increase, as well as pt develops hip hike on left and her BOS moves forward in walker. Pt has ambulated without assistive device x 1 with HHA/mod assist for balance and increase of above mentioned gait deviations.
Pt/Family Education: Pt's father and sister educated on pt transfers and safety. PT reviewed car transfers with pt and her father. PT also educated pt and her father on mobility and safety for household ambulation. PT educated pt on importance of pacing and time management with physical activities.
Long Term Goal Status:
Assessment: Pt is a 38 y/o bf diagnosed with Guillain-Barré who has made excellent progress during her rehabilitation stay. Pt has advanced to ambulating with a wheeled walker with only SBA and pt is ready to decrease stability of assistive device with outpatient PT. Pt has also shown almost full return of bilateral LE musculature but will continue to require daily strengthening to maximize return. Pt has much potential to return to premorbid state of physical functioning. Pt was most limited in therapy by pain in either her left hip or bilateral feet, but pain continues to subside with increased physical functioning.
Recommendations: PT recommends outpatient physical therapy 5x a week to increase bilateral LE strength and help pt to achieve premorbid level of physical functioning.
Therapist: Karen Wingert, PT, RN.
Linda has returned to her full-time job as a computer operator for the University of Missouri. Linda walks unlimited distances and completes all ADLs without assistance. The only residual symptoms are occasional numbness and tingling in both feet.