Walk Speak Eat

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• Walk Speak Eat -
• Peach face and the 3rd element.
• JHH Medical Grand Rounds 12.05.05
• David Kellett
• Rehabilitation Registrar

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• Case Presentation
• 29 y.o. male
• Unwell 5 days
• Poor appetite drinking water
• Slurred speech
• Difficulty walking poor balance/fall
• Confused

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• Background
• Bipolar disorder
• DSP
• Lives with family

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• Physical Examination
• Pale confused vomiting
• T 38.9 P 134 R 30 02 94 BP 120/60
• Tone increased
• Ataxia and dysarthria
• Vertical nystagmus
• Left basal crackles

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• ECG sinus QTc 400
• U/A normal
• Polyuria 500ml/hr

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• Investigations
• EUC 118/ 4.0 / 88 / 17 / 90 / 16
• FBC WCC 8.1 Hb 135 Plt 148
• ABG pH 7.48 pCo2 24 pO2 77 BE -4.6
• CRP 149

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• CK 80
• Lithium 0.92 (0.6-1.2)
• Glucose 8.9
• Calcium 2.27
• TSH 2.74

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• CT

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• Problems
• Febrile
• Neurological signs
• Hyponatraemic
• Polyuric

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• Provisional diagnosis
• Lithium toxicity
• Nephrogenic DI
• CAP
• NMS
• Herpes encephalitis

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• Initial Management/ongoing investigation
• CT brain
• LP/blood culture/Urine/Sputum MCS
• Atypical serology
• Acyclovir
• Ceftriaxone/ pen/ diclox/ genta/ azith
• ICU consult
• IV fluids

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• Fluid management
• 10 litres / 24hrs (9L normal saline)
• Sodium 118 128 133 136 139
• Chloride 88 97 106 107 110
• Serum osmolality 284 (day 3)
• urine osmolality 603 (day 3)

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• ICU review
• Semi-elective intubation and ventilation
• Extubated 72hrs
• Fever settled

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• Medical ward (day 5)
• Persisting neurological signs
• MRI
• Atypical serology chlamydia psittaci
• Delusions relating to interpersonal relationships
  and religion

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• Further history
• Peach face recently purchased from a pet store
  died shortly before patient became unwell.

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• Rehabilitation assessment
• Impairments
• Swallow
• Speech
• Movement related functions
• Mental functions

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• Activity and participation
• Limitation of -
• Communication - dysarthria
• Self Care - eating
• - grooming
• - bathing/dressing
• - toileting
• Social Interaction
• Mobility

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• Rehabilitation Ward - Day 43
• Swallow and communication
• Upper limb/self care
• Mobility
• Discharge environment/services
• Carer training
• Mood/cognition

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• Rehabilitation Progress
• Movement
• - sit to stand with 1 person
• - assisted wheelchair mobility
• - independent bed mobility
• - FASF and 2 assistants

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• 2. Speech
• - dysarthria therapy
• - imprecise articulation, loudness control,
  nasal emission
• - increased speech intelligibility with
  generalisation of articulation skills into
  general conversation

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• 3. Swallow
• Diet upgraded (incl. thin fluids)
• Safe swallow techniques

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• 4. Self care
• Light assistance washing back/bottom
• Independent upper body dressing
• Independent grooming

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• 5. Home environment
• Discharged to grandmothers home with brother
• Portable ramp for wheelchair access
• Achieved 180 degree pivot transfer with 1
  assistant to access toilet

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• 6. Follow-up
• Rehabilitation medical outpatients
• - day hospital (SP/OT/PT)
• Mental Health Team
• Community options case management
• Baptist community care domestic support

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• Discharge medication
• Olanzapine 10mg bd
• Pericyazine 10mg bd
• Sodium valproate 1700mg/d
• Admission FIM 63/126
• Discharge FIM 86/126
• Rehabilitation admission 29 days

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• More problems !
• 2 months after discharge
• Worsening dysphagia
• Depressed
• Barium swallow confirmed aspiration
• Readmission to rehabilitation

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• Management
• Downgrade diet consistency/swallowing strategies
• Psychiatry assessment
• Neurology assessment
• decrease in pericyazine (EPS)
• increase in venlafaxine
• addition of cogentin

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• Health maintenance
• Swallowing/aspiration
• Skin care/pressure ulceration
• Weight/nutrition
• Cardiovascular system
• Bone metabolism
• Falls
• Posture/joint ROM
• Mood

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• Summary
• Bipolar disorder
• Lithium neurotoxicity
• Nephrogenic DI
• Chlamydia psittaci/atypical pneumonia
• Significant disability

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• International Classification of Function
• Formerly ICIDH
• Companion to ICD
• Describes impact of injury/illness
• 1. Impairment
• 2. Activity
• 3. Participation
• 4. Context

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• Impairment
• Body structure and function
• Nervous/mental
• Eye/ear/sensory
• Voice and speech
• CVS, haem, immune, respiratory

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• Impairments cont.
• 5. Digestive, metabolic, endocrine
• Genitourinary and reproductive
• Neuromusculoskeletal
• 8. Skin

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• Activities and Participation
• Learning and applying knowledge
• General tasks and demands
• Communication
• Mobility
• Self-care

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• Activity and Participation
• 6. Domestic life
• 7. Interpersonal interactions /relationships
• 8. Major life areas (work,education)
• 9. Community, social and civic life

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• Context
• Environment
• Products and technology
• Natural and human modified environment
• Support and relationships
• Attitudes
• Services, systems and policies
• Personal factors