Chapter 6: Evaluation of the Client With a Neurologic Lesion: Case Study

For the Instructor Guide and Worksheet Key please contact user services at userservices@mheducation.com

OUTLINE

Objectives:

The student will appropriately:

1. Apply clinical reasoning to the evaluation of a client with an upper motor neuron lesion to determine key impairments of body structure and function.

2. Apply clinical reasoning using the Framework for Examination Decision Making to determine the key impairments to be addressed to improve function at the activity and participation level.

3. Select appropriate outcome measures based on examination findings.

4. Generate a prognosis based on examination findings.

5. Write appropriate short- and long-term goals for the client in the case study.

Activity 1. Complete the Framework for Examination Decision Making

In this section students use the Framework for Examination Decision Making to work through their clinical reasoning for the evaluation of a client with stroke using the Sandra case that was used in Chapter 4.

Activity 2. Is Your Clinical Reasoning Cohesive?

Students work through questions to help them examine the cohesiveness of their group's clinical reasoning.

Activity 3. Case Study: Budd

Students work through a case of an acute stroke applying the Framework for Examination Decision Making to a sit to/from stand activity.

Activity 4. Case Study: Lynn

Students work through a case of an acute stroke applying the Framework for Examination Decision Making to ambulation.

WORKSHEET

I. EVALUATION:

This is your thought process leading to confirming or denying your hypotheses. This may:

1. Include synthesis of all data/findings gathered from the examination, highlighting pertinent factors.

2. Take various forms if part of documentation: problem list, statement of general assessment with key factors influencing status.

II. DIAGNOSIS:

Describe how the identified limitations in body structure/function and activity restrict the client's desired participation role(s), and whether or not PT can have a beneficial effect.

State the International Classification for Disease 10 Code(s) (ICD 10 code).

III. PROGNOSIS (Goals and Outcomes):

Provide a statement on the client's long term predicted functional prognosis and identify the short- and long-term goals for this episode of care (level of care). Here are some areas you might want to address:

1. What is the potential for function or participation for the long term? for the affected parts of the body?

2. What specific motor functions should the client be able to achieve this time (this level of care)?

3. Identify the positive factors that will contribute to the achievement of the goals.

4. Identify the attributes that might prevent or delay the acquisition of the goals.

5. Identify the likely timeframe for achieving the long-term ...