Home Health Neurological Examination Case Report Examples

Neurological Examination Case Report Examples

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Case Report 1: Philip

Spinal Cord Injury at the Level of C7 Vertebra

Philip sustained crush injury resulting in C7 spinal cord injury and complete quadriplegia. Quadriplegia is considered complete when sensory and motor functions below the level of injury are completely absent (Lightbody, 1998). In this type of injury, there is damage to ascending sensory (spinothalamic) and descending motor (lateral and ventral corticospinal) tracts of the spinal cord resulting in motor and sensory dysfunction. A C7 injury leads to paralysis of the extensor of the elbow (triceps), while the flexor (biceps) and extensor of the wrist (extensor carpi radialis) is spared (Kirschblum, 2007). The rest of the upper limb and lower limb muscles; and bowel and bladder are involved. Features of upper motor neuron lesion with spastic paralysis develop.

Neurological Examination Case Report Examples

Additionally, in cervical cord injury, there is autonomic system disruption. Uncontrolled sympathic behavior is below the injury level due to a lack of cerebral control and uncontrolled parasympathetic behavior above the injury level (Kirschblum, 2007).

Impact on Occupational Performance

A spinal cord injury at the level of C7 has a favorable projected motor outcome one year after the injury (Kirshblum, 2007). Although occupational performance in most areas of the activities of daily living, vocational and leisure activities will be affected, the effect is likely to be minimal, and the patient for each of these fields, with or without the use of adapted equipment and technological improvements is required to become autonomous (Kirschblum, 2007).The patient may need support from friends and family members in a few activities though.

So far as daily living activities are concerned, feeding, grooming, preparing a light meal, and upper extremity dressing can be autonomously performed. However, bowel and bladder care, lower extremity dressing, and bathing require assistance (Kirshblum, 2007). Vocational performance may be affected in the sense that wheelchair propulsion across rough surfaces and curbs requires aid (Kirschbaum). However, in Philip’s case, vocational rehabilitation is likely to be very successful because of the managerial nature of his job. Also, leisure activities that the patient used to perform before the injury, namely gardening and sports, will need modification in technique and equipment as appropriate because mobility and transfers need assistance and a wheelchair.

Assessment of Component Skills

Philip’s biomechanical and sensorimotor component of occupational performance needs assessment in the tasks that his job requires (Chapparo & Ranka, 1997). As a part of a biomechanical assessment, upper limb movements need to be comprehensively evaluated. Muscle power, range of motion, weight transfer, etc. are assessed. Shoulder movements, arm wrist, and forearm extension and flexion are tested. Gross and fine coordination and ability to write, hold objects of daily use and perform activities like dressing and grooming are assessed (Hoffman, Hannetona, Roby-bramia, 2006). In addition to motor evaluation, assessment of upper limb sensation as a part of the sensorimotor component is important for the rehabilitation program. It has been found to correlate with the recovery of motor power in the future (Lightbody, 1998).

The dynamics of social and psychological aspects of his interpersonal relationships and interaction with the family members need evaluation (Chapparo & Ranka, 1997). Before sustaining an injury, he was actively involved in the activities of his son and wife. Post-injury, although his wife is assisting him in his daily activities, he doesn’t like her to play the role of a caregiver. Physical aspects of marital life are also likely to be affected as a result of the spinal cord injury. Also, he may no longer be able to coach his son in his football practice. On the contrary, he may require the assistance of his family members to perform some tasks. All of these necessitate an assessment of the extent of cooperation and communication between the family members.

Occupation Therapy Interventions

Possible interventions within the scope of an occupational therapist, in this case, are the evaluation of the job site and work-related training as a part of vocational rehabilitation, those targeting activities of daily living and leisure, and functional skills that have been impaired as a result of the injury (Chapparo & Ranka, 1997). In a quadriplegic patient, the most important intervention is equipment related intervention, i.e., the use of a wheelchair for mobility enhancement. A lightweight manual wheelchair, which is custom made, rigid or folding frame, is important to maintain independence, mobility, avoiding pressure sores, and skincare(Kirschblum, 2007). Also, he needs education regarding the use of a sliding board for transfers, with or without assistance (Kirschblum, 2007). Regarding activities of daily living such as bathing, grooming, etc., some modification of equipment is required. For leisure activities, the patient may choose to indulge in some pre-injury activities or be advised to pursue different activities with the same interests. As the patient has been an in-patient until now, apart from activities of daily living, he is likely to require more interventions to target his social and leisure tasks, once he is discharged home.

As part of vocational rehabilitation, an occupational therapist evaluates the patient in terms of muscular function, mobility, coordination, and sensory and cognitive deficits. The patient’s physical capacities are then matched to the physical demands of the job, which the patient had before the injury (Désiron, de Rijk, Hoof, & Donceel, 2011). After this comprehensive evaluation, a task-focused approach is used to enable the patient to develop confidence and self-esteem to accomplish a hierarchy of tasks (Désiron, de Rijk, Hoof, & Donceel, 2011).

Case Report 2: Lucy

Traumatic Brain Injury

Post-traumatic brain injury, Lucy is having difficulty in articulating sentences, speech production, and writing. These are the features of Expressive aphasia, also called Broca’s aphasia, which is a language disorder characterized by a nonfluent speech, short abbreviated and grammar-less phrases, and problems in Reading, though comprehension and reading skills are primarily retained (Fadiga, Craighero & D’Ausilioa, 2009). The affected structure in this type of aphasia is The area of Broca, which lies in the lower left hemisphere frontal gyrus of the brain, represented as Brodmann’s area 44 and 45. This area is responsible for motor aspects of speech, that is, speech production. However, recent studies have found involvement of Broca’s area in the comprehension of syntactically complex material also (Fadiga, Craighero & D’Ausilioa, 2009).

Associated features of right-sided hemiparesis of upper limb suggest cortical dysfunction. The lesion in the left frontal gyrus affects motor function in the contralateral limbs; hence, the association of aphasia with right upper limb hemiparesis(Fadiga, Craighero & D’Ausilioa, 2009). Also, as Lucy finds it difficult to coordinate actions with the right hand unless she is visually monitoring the activity, there is probably an impairment of the joint position sense and stereognosis caused by cortical sensory loss. An additional tool for the localization of these symptoms in Lucy would be neuro-imaging studies.

Impact on Occupational Performance

Because of the injuries, occupational performance areas that are likely to bear the brunt are self-maintenance, productivity, and leisure occupations (Chapparo & Ranka, 1997). Her work as a hairdresser requires precision and coordination in hand movements. Thus, the maximum impact of the head injury is going to be on her vocation. In her leisure time, Lucy enjoyed tennis and golf as her recreational activities. Again, both these activities necessitate hand coordination and strength. However, due to likely frontal motor cortex damage and cortical sensory loss, in-coordination, and hand weakness in right upper limb has resulted. Thus, associated leisure tasks are also likely to be affected.

Due to difficulty articulating sentences, the patient may have difficulty expressing her feelings and emotions and may have communication problems. This can lead to social withdrawal, feelings of isolation, an uncaring attitude, and depression (Peloquin, 2000). This can affect her occupational performance in the interpersonal area.

Assessment of Component Skills

Assessment of dimensions of the sensory-motor component, interpersonal component, and cognitive component is performed (Chapparo & Ranka, 1997). From the patient’s perspective, a complete neuromuscular and sensorimotor evaluation is performed to evaluate coordination and limb weakness (Chapparo & Ranka, 1997). Muscle strength and reflexes in the right upper limb and rest of the limbs are graded, and patient’s fine and gross coordination skills, laterality, postural alignment, and visual-motor integration are tested in the context of the tasks that need to be performed by the patient. Sensory system assessment includes proprioception, stereognosis, depth perception, and other senses (Chapparo & Ranka, 1997).

A cognitive and psychosocial assessment is required given the history of head injury, lack of self-confidence, and apathy. Cognitive assessment includes memory, learning, orientation, judgment, problem-solving, decision making, initiation and termination of activity, etc. about her work (Désiron, de Rijk, Hoof, & Donceel, 2011). A psychosocial assessment is done regards apathy, neglect, and awareness in the patient. Her psychological, social, and self-management components are assessed. The skills about these are her interests, perception of self and expression of self, social conduct and behavior, and interpersonal relationships compared to the pre-injury state (Chapparo & Ranka, 1997).

Occupation Therapy Interventions 

The goal of occupational therapy interventions in this patient is to restore her participation in her career, activities of daily living like cooking, cleaning and shopping, and her leisure activities, which are golf and tennis. Possible interventions in an occupational therapy plan for this patient are neuromuscular, adaptive, musculoskeletal, cognitive, and educational interventions (Radomsky & Latham, 2008).

Neuromuscular interventions are required in her case in postural awareness, balance training, muscle strengthening, one-handed skills, and improving the range of motion (Chapparo & Ranka, 1997). All these interventions aim to improve the upper extremity function.

In Lucy’s case, an educational intervention can be one of the most effective ones to address occupational performance issues. These interventions target the patient as well as the family members. As she has plans to get married, her boyfriend is also involved in the education process. Education relating to home management, community integration, self-grooming, daily living activities, and social skills is given (Chapparo & Ranka, 1997). The importance of speech therapy for the treatment of aphasia is explained to the patient and caregivers.


Case 1

  • Chapparo, C., & Ranka, J. (1997). Occupational Performance Model (Australia): Monograph 1(pp. 1-23). Sydney: Total Print Control. Retrieved from www.occupationalperformance.com/
  • Désiron, H. A. M., de Rijk, A., Hoof, E. V., & Donceel, P. (2011). Occupational therapy and return to work: a systematic literature review. BMC Public Health, 11, 615.Retrieved from http://www.biomedcentral.com/1471-2458/11/615
  • Hoffmann, G., Hannetona, L. & Roby-bramia, A. (2006). How to extend the elbow with a weak or paralyzed triceps: control of arm kinematics for aiming in C6–C7                quadriplegic patients. Neuroscience, 139, 749–765.
  • Kirshblum, S. C., Priebe, M. M., Ho, C. H., Scelza, W. M., Chiodo, A. E., & Wuermser, L.  A. (2007). Spinal cord injury medicine 3. Rehabilitation phase after acute spinal cord injury. Archives of Physical Medicine and Rehabilitation, 88, s62-s70.
  • Lightbody, S. (1998). Assessment of upper limb sensation in patients with complete  quadriplegia. Australian Occupational Therapy Journal, 45, 18-22.

Case 2

  • Chapparo, C., & Ranka, J. (1997). Occupational Performance Model (Australia): Monograph 1(pp. 1-23). Sydney: Total Print Control. Retrieved from www.occupationalperformance.com/
  • Désiron, H. A. M., de Rijk, A., Hoof, E. V., & Donceel, P. (2011). Occupational therapy andn return to work: a systematic literature review. BMC Public Health, 11, 615. Retrieved from http://www.biomedcentral.com/1471-2458/11/615
  • Fadiga, L., Craighero, L., & D’Ausilioa, A. (2009). Broca’s area in language, action, and  music: The Neurosciences and Music III—Disorders and Plasticity. Annals of New      York Academy of Sciences, 1169, 448–458. doi: 10.1111/j.1749-6632.2009.04582.x
  • Peloquin, S. M. (2000). Occupation as therapy: activity as a therapeutic tool. In A. J. Punwar, & S. M. Peloquin (Eds.). Occupational Therapy: Principles and Practice (pp. 39-51). Philadelphia:  Lippincott, Williams & Wilkins.
  • Radomski, M. V. & Latham, C. A. T. (2008). Occupational therapy for physical dysfunction (6th ed.). Philadelphia: Lippincott Williams & Wilkins.

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