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Examination

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History

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  • Demographic Information:

    The patient is a 71-year-old right-handed man with a large, right-sided cerebellar brain tumor status post-resection and ongoing chemotherapy.

  • History of Present Illness:

    Two years ago the patient developed an insidious onset of headache, nausea, vomiting, and progressive gait instability. A visit to the emergency department and subsequent magnetic resonance imaging revealed a large right cerebellar mass measuring 4 cm (1.6 in.). He underwent tumor resection 5 days later. The pathology report revealed Stage 4 glioblastoma multiforme. At that time, he required a wheelchair as his primary mode of locomotion. He was then sent to inpatient rehabilitation for 3 weeks and chemotherapy and radiation was initiated, which was completed 6 months ago. The patient is now taking an experimental study drug to prevent tumor regrowth and was referred to outpatient physical therapy to address incoordination and impaired balance and gait. He failed a driving test 1 month ago owing to coordination impairments. In the last 6 months, he has not required an assistive device and has not experienced any falls.

  • Medical History:

    Patient has a history of hypertension. Current medications include methylphenidate, atenolol, and levetiracetam.

  • Social History:

    The patient is married, lives with spouse, and is a retired mechanical engineer. Wife is very supportive. Patient is active in church activities and enjoyed bicycling.

  • Living Environment:

    Patient lives in a multiple-level home with three flights of stairs. He has the following durable medical equipment: wheelchair, front-wheeled walker, cane, and gait belt.

  • General Health Status:

    Good. His prior level of functioning was fully independent and active. Before brain tumor diagnosis, the patient rode his bicycle from California to Florida.

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The authors extend their thanks to Elizabeth Trawinski, Idaho State University, for her assistance in preparing this case study.

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Systems Review

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  • Cardiovascular/Pulmonary System:

    • Blood pressure: 132/77

    • Pulse: 63 beats per minute

    • Respiratory rate: 17 breaths per minute

  • Musculoskeletal System:

    • Height: 5 ft, 9 in.

    • Weight: 147 lbs

    • Gross symmetry: normal anatomical symmetry; with movement, right hemibody ataxia greater than left (Fig. CS11.1)

    • Gross range of motion (ROM): within normal limits (WNL) bilaterally

    • Gross strength: generally 5/5 throughout both upper extremities (UEs) and lower extremities (LEs), except mild impairment in right grip strength

  • Neuromuscular System:

    • Sensation: intact for light touch, pressure, and joint position sense of hallux and ankles

    • Coordination: impaired

    • Tone: normal

    • Postural control: impaired in both sitting and standing

    • Balance: impaired static and dynamic balance

    • Gait: ataxic gait; requires close supervision without an assistive device

    • Cognition: mild impairments in short-term recall (able to recall two of three items after 10-minute period). Patient reports difficulty with complex thought processes.

  • Integumentary System:

    • Surgical site on scalp healed well

    • Otherwise intact

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FIGURE CS11.1

Postural examination The patient demonstrates normal postural alignment during static standing.

Graphic Jump Location
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Tests and Measures (initial examination)

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