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The patient is a 60-year-old Hispanic male employed as a farm worker in an orchard in Kern County, California. His work primarily involves pruning trees, which entails maneuvering through tight spaces, climbing ladders, and handling farm machinery and gardening equipment. The patient was brought to the hospital emergency department with complaints of severe headache, dizziness, nausea and vomiting, and an inability to walk. For the last 2 months, he has had a chronic cough, occasional shortness of breath, generalized weakness, and joint pain. On physical examination, the patient was noted to have skin lesions on his nose and arms. Further medical work-up including blood tests and magnetic resonance imaging (MRI) of the brain and spinal cord indicated that the patient had coccidioidomycosis with resulting pneumonia, meningitis, and hydrocephalus. The MRI scan showed a dilated lower half of the fourth ventricle. Cystic lesions that were likely cocci granulomas were identified in the C1-C2, C6-C7, and T6-T7 spinal cord segments. Medical interventions included antifungal medications and ventriculoperitoneal (VP) shunt placement. On the third day of hospitalization, the patient was referred to physical therapy to address limitations in functional mobility, transfers, and gait. Prior to the hospitalization, the patient lived at home with his wife. He was active in the community and had no history of drug or alcohol abuse. At the time of examination, there were no bowel/bladder changes, no headache, and no nausea or vomiting. Although the patient's primary language is Spanish, he speaks some English. When asked about his goals, the patient stated “I want to be able to walk again.” His current medications include acetaminophen, bisacodyl suppository (Dulcolax), chlorhexidine, clotrimazole topical (Lotrimin), famotidine (Pepcid), heparin, voriconazole, fluconazole, and prednisone.

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What are possible complications interfering with physical therapy?

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What are the most appropriate physical therapy outcome measures for gait and balance?

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What are the examination priorities?

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Based on his health condition, what do you anticipate will be the contributors to activity limitations?

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  • CEILING EFFECT: Psychometric property of an outcome measure in which the instrument is unable to detect a further increase in score for the highest-scoring individuals
  • PART-TO-WHOLE TASK PRACTICE: Method of structuring therapeutic interventions based on motor control and motor learning theories whereby a task is broken down into smaller components that the individual practices with gradual progression toward performing the whole task
  • VENTRICULOPERITONEAL (VP) SHUNT: Surgically placed drain that runs subcutaneously between the fourth ventricle and the abdominal cavity; used to treat hydrocephalus and increased intracranial pressure caused by excessive cerebrospinal fluid

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  1. Describe the typical signs and symptoms of coccidioidomycosis affecting the central nervous system.

  2. List pertinent tests and measures used in a physical therapy examination for a hospitalized patient with meningitis and hydrocephalus secondary to coccidioidomycosis.

  3. Discuss appropriate physical therapy interventions for a person with movement dysfunctions secondary to coccidioidomycosis.

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