Patient Background Story
Anh is a 65 year old woman, who is currently an inpatient at a Sydney rehabilitation hospital. Approximately, 5 weeks ago, Anh was found by her husband slumped in bed. She was unable to speak and could not move her right side. Anh was diagnosed with a left middle cerebral artery stroke. Fol owing acute management in a tertiary hospital, Anh has been a patient in the rehabilitation hospital for the last week. Past Medical History (Health Profile)
Deep Venous Thrombosis (2 years ago after travelling to Vietnam – treated with warfarin for 6 months) Family history of vascular disease (Father died at 58 from myocardial infarction, mother died at 64 fol owing a stroke) Current Medications
Immediate Concerns
Anh’s stay in the stroke unit of the tertiary hospital was complicated by depression. On leaving the acute care hospital, Anh was on a restricted diet with thickened fluids. She was unable to mobilise and remained withdrawn and a reluctant participant in physical and occupational therapy. Her family are asking ‘when wil she be able to come home?’ Physical Assessment
Cognitive Assessment
Anh has been formal y assessed. The comment was made by the neuropsychologist that the testing was severely limited by the patient’s receptive and expressive aphasia. Within the limits of the testing Anh performed poorly on most memory and cognitive tasks. The neuropsychologist further commented that the findings could be confounded by underlying depression. Anh was fluent in both English and Vietnamese, but now speaks only a few words, mostly in Vietnamese. She can say “yes” and “no” in English. Psychological Assessment
Anh appears withdrawn and becomes frustrated when she tries to speak. Anh’s family have stated that she seems withdrawn and shows little interest in her grandchildren when they visit. Social Assessment
Anh has been married to Tranh for 43 years. He is a university law lecturer. Anh has not worked since the birth of her first child. They have three adult children (son and two daughters), who are all married with children. The youngest daughter still lives at home and has a 7 month old baby. Anh’s other daughter lives in Singapore with her husband and 2 children. They both have executive positions and return to Australia twice a year. The son has three children, one at school. Anh was the primary carer for 3 grandchildren (7 month old and son’s 2 pre-school children) during the week. The two children were dropped off at 7am by their father and picked up at 6pm. Anh’s illness and hospitalisation has impacted significantly on family dynamics. In addition, the family has a large circle of extended family and friends who regularly gather at Anh’s house. Additional notes
The discharge planning team are meeting to decide if and when Anh will be discharged home. You are the multidisciplinary team tasked with developing a comprehensive plan for Anh during her rehabilitative phase. Describe your priorities during this 4 week phase, justify who would be the lead professions and how they would be supported by the remainder of the team. Consider other health professionals outside of your team you may want to involve in Anh’s care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

Source: http://www.aippen.net/docs/CS7_SuppDoc2_LocalHCTC.pdf

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