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1、復(fù)健科案例聯(lián)合討論會Intern彭夢婷DirectedbyResidentDr.陳泰宗DirectedbyAttendingDr.陳芝琪8H02AGeneralDataChartNo.:2019784XName:王X豐Age:50yearsoldSex:maleMarriage:SingleOccupation:PublicservantRace:TaiwaneseGeneralDataAdmissionDate:2009/8/2TransferDate:2009/9/7HospitalizationDays:44DaysReh
2、abilitationDays:11DaysPremorbidFunctionalstatus:wellPremorbidADL:independentMajorDiagnosis:Traumatic,closedheadinjury,complicatedwithbilateralSDHofhemispheresulciandrightfrontalICH,complicatedwithbrainedemawithleftmidlineshiftStatuspostICPmonitorimplantationon2009/08
3、/03RightF-T-Pcraniectomyon2009/08/04RightfrontalandtemporalpartiallobectomytoremoveICHon08/04MajordiagnosisOrganicbrainsyndrome,presentedwithpersonalityandbehavioralchangesIntermittentdisorientationSelf-talkingRestlessbehaviorEasilyhottemperAgitationPoorsleep,fairapp
4、etiteUnderlyingdiseaseTypeIIDiabetesMellitus,newly-diagnosed,underoralhyperglycemicagents’controlEssentialhypertension,underfairmedicalcontrolAssessment(8/28atNSward)MentalstatusGlasgowComaScale:E4VaM5LanguageandSwallowingNaming:poorComprehension:poorRepetition:poorM
5、anner:poorValidity:poorSwallowing:nodysphasiaIntubationNoFoleytube,noNGtube,notracheostomyAssessmentBrunnstrom'sstageupperextremities(P):IV(right)II(left)upperextremities(D):IV(right)II(left)lowerextremities:IV(right)II(left)MusclePowerupperextremities(P):4(right)2(l
6、eft)upperextremities(D):4(right)2(left)lowerextremities:4(right)2(left)AssessmentFunctionalstatusRolling/sitting/standing:poorAmbulation:unableKatzindexofADLBathing/dressing/toileting/transfer/feeding/continence:totallydependentANS:BladderIncontinence,ondiaperANS:Bow
7、elIncontinenceRehabilitationPlanningPhysicaltherapyPassiveROMStretchingtrainingEndurancetrainingAmbulationtrainingPoorrehabilitationpotentialCurrentMedicationForessentialhypertensionValsartan160mgBIDForNIDDMMetformin500mg1#TIDGliclazide60mg2#BIDAcarbose50mg1#TIDSitag
8、liptin100mg1#QDForOrganicbrainsyndromeQuatiepine25mg3#IRREAssessment(9/7at5Gward)Urine/stool:incontinence/incontinence,ondiaperNoNG
