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Riddhi Patel
Acute Rehabilitation
April 28 and 29, 2014
Post-Clinical Rotation Report: Acute Rehabilitation
1. Relate situations, incidents or cases that interested you on this rotation.
During my first rotation, I observed a 90 years old female with a Right sided- Middle Cerebral
Artery, Atrial Fibrillation, HTN, Hypothyroidism, Left sided Hemiparesis (one-sided weakness),
CHF, Phlebitis, and some other symptoms consistent with her stroke. I have already researched CVA
before and I wasn’t very familiar with Middle Cerebral Artery or Hypothyroidism, so I decided to
learn about them in greater depth. Middle Cerebral Artery (MCA) stroke refers to the sudden
neurologic deficit resulting from brain infarction or ischemia in the region supplied by the MCA.
MCA is the largest cerebral artery and the one most often affected by cerebrovascular accident
(CVA). It supplies most of the basal ganglia, anterior and posterior internal capsules, and most of the
outer convex brain surface. Results include diverse neurologic deficits; symptoms differ in patients
depending on the area and extent of damage. Services for MCA stroke patients usually include
dysphagia screening, anticoagulation therapy for A. Fib/flutter, discharged on statin medication,
stroke education, smoking cessation education (if applicable), appropriate and expedient use of
thrombolytic therapy, etc. A modified barium swallow or video fluoroscopy is used to ascertain if
any feeding is safe to avoid Aspiration pneumonia which generally occurs due to penetration of
food, saliva and gastric acid. Pulmonary Embolism and Deep Vein Thrombosis along with post
phlebitis syndrome impede recovery for patients after stroke. To counter these, pneumatic
compression devices/stockings can be used, or daily, low dose heparin can be administered
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subcutaneously to reduce the chances of DVT. The focus is on restoring function rather than
improving impairment; neural plasticity plays a major role in the patients’ recovery efforts.
Equipment involved in the patients’ recovery plan include gait-assistive devices such as a four wheel
walker and a single point cane, and activities-of-daily-living aids which are designed to maximize
functional independence with basic tasks such as feeding, dressing, and grooming. Some medication
used to treat MCA stroke patients include Hematologic agents (risk of increased bleeding) like
Warfarin, Aspirin, Dabigatran and Rivaroxaban, Anti-hypertensives (ACE inhibitors and Betablockers for rate control), Statins such as Simvastatin, Atorvastatin, and Lovastatin, Antispasmodics
(muscle relaxants; side effects: drowsiness) such as Baclofen and Dantrolene, and other
anticholinergics. Hypothyroidism is a condition where the thyroid gland doesn’t produce enough of
certain important hormones; most prevalent in women above the age of 60. Signs and Symptoms
include fatigue, dry skin, puffy face, constipation, elevated blood cholesterol level, hoarseness,
impaired memory, depression, slowed heart rate, thinning hair, etc. Thyroid gland produces
Triiodothyronine and Thyroxine which maintain the rate at which the body uses fats and carbs, and
all other aspects of metabolism. Cause can be an autoimmune disease where the antibodies of the
patient’s own immune system is affecting the thyroid’s ability to produce hormones. Other risk
factors include congenital disease, pituitary disorder (not producing Thyroid Stimulating hormone),
radiation therapy, and iron deficiency. Blood tests (including TSH test) can indicate hypothyroidism
with low level of thyroxine and a high level of TSH. Standard treatment involves daily use of the
synthetic thyroid hormone levothyroxine; this oral medication restores adequate hormone levels and
reverses the S/S of hypothyroidism. Side effects may include insomnia, shakiness, and increased
appetite until the proper dosage is determined.
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2. Describe the variety of procedures and/or treatments you observed being performed in this
department.
On my second rotation, we had two patients- one with Total Knee Arthroplasty and the other one with
Acute CVA and Sjogren syndrome. Also, the following two medications seemed to be very prevalent
with these conditions: Xarelto and Neurontin. So, I wanted to learn about these two things in a bit more
detail. Sjogren syndrome is a disease of the immune system identified by two main symptoms- dry
mouth and dry eyes. Most often, accompanies other immune system disorders such as lupus and
rheumatoid arthritis. The mucous membranes and moisture-secreting glands in the eyes and mouth are
affected, resulting in decreased production of tears and saliva. It is most common among women and
those above the age of 40. Besides dry eyes and mouth, joint pain, vaginal dryness, persistent dry cough,
swollen salivary glands, swelling and stiffness, and prolonged fatigue are some other symptoms. It is
also an autoimmune disorder (immune system mistakenly attacking body’s own cells and tissues);
certain genes increase the risks of developing this syndrome but a triggering mechanism such as a
virus/bacterium is also needed. After the glands of the eyes and mouth, the immune system may also
target joints, thyroid, kidneys, liver, lungs, skin and nerves. Yeast infections, dental cavities, and vision
problems may also develop. Blood tests may be ordered to check for levels of different types of blood
cells, blood glucose levels, indications of problems with liver and kidneys, presence of antibodies
common in Sjogren syndrome. Some eye tests such as Schirmer tear test helps assess tear production.
Imaging such as Sialogram (x-ray to test the amount of saliva that flows into one’s mouth) and chest Xray (lung inflammation can suggest Sjogren syndrome). Medications such as Salagen and Evoxac are
prescribed to increase saliva production, non-steroidal anti-inflammatory drugs (NSAIDS) may be
helpful along with antifungal medications that help treat yeast infections in the mouth. Neurontin is also
known as Gabapentin, an anticonvulsant/antiepileptic drug which is used with other medications to
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prevent and control seizures and to relieve nerve pain following shingles. It may also be used to treat
other nerve pain conditions such as diabetic neuropathy, trigeminal neuralgia, and restless legs
syndrome. It is to be taken by mouth, with or without food. Works best when taken regularly at a
constant dosage. Some common side effects include drowsiness, dizziness, blurred vision, tremors, sore
throat, swelling of the hands/ankles/feet, depression, chest pain and trouble breathing. Should be limited/
avoided during pregnancy, a kidney disease, and with alcoholic beverages. Keep the dosage consistent;
store the medication at room temperature away from light and moisture. Antacids containing aluminum
or magnesium will interfere with the absorption of Neurontin in the body.
3. Summarize your impression on how the patients seem to respond to the care given in this
department.
The patients in the department seemed to be responding relatively well. The recovery rate varied
depending on individual patients- their personalized conditions/allergies, family support, age/gender,
medical history, etc. But for the most part, the patients were pretty healthy and content and were
showing a lot of improvement (the treatment plans seemed effective as test results indicated the
abnormalities being brought under control). The patients seemed to appreciate the interactions with the
staff and the care being provided (except, a few patients seemed agitated due to a delay in their bathing
time).
4. Assess the quality of health care delivered in this department by comparing the adequacies and
deficiencies you have observed. Make one recommendation for improvement.
The patients were well taken care of; there seemed to be no complaints from patients’ end. The nurses
did their best to make sure the patients had their tests, medications, and food in a timely manner. They
coordinated the treatment plans between the various departments such as Cardiology and Physical
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Therapy and sometimes with their individual surgeons/Physicians and/or the Pharmacy department for
the newer medications. But while we were helping deliver the patients’ questions about when they were
going to have their bath, if they could get a basin sent to their room to brush their teeth, etc. to some of
the nurses, they seemed a little ignorant/ disinterested. So, perhaps, the department staff could try to
address the patients’ concerns more efficiently/quicker.
5. Consider one or more topics of information that you feel you would need to research to help
you perform in this department.
To be able to perform well in this department, one should be very keen at finding warning signs and
symptoms such as bed sores, any swelling, or other skin ailments. One should be humble, polite and
patient to be able to provide the patients with the best possible care- fixing their beds, bringing them
food, checking on them every so often, helping them gain control over their daily life activities, etc.
They should be very familiar with Vital Signs (normal ranges, how to take them, what they signify),
frequently prescribed medications (normal uses, dosage, side effects, etc.), commonly performed
procedures/ prevalent conditions- CVA, TKA, MI, etc., basic understanding of the human anatomy and
physiology, and a background knowledge on the various tests- CT scans, blood tests, EKG, ABGs,
Neuro-checks, etc.
6. Evaluate the personal traits or characteristics you feel are needed by persons who work in this
department.
Professionals working in this department would need to be able to communicate effectively, explaining
in such a way that the patient/ patient’s family can easily understand. They often work with people who
are dealing with stressful and difficult situations, so they must be compassionate and empathize with
their clients. They must be able to develop and maintain a good working relationship with all kinds of
people. Good listening skills are crucial in order to understand the patient’s problems, concerns, and
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values; sometimes all they might need is someone to listen to them. They must also have patience as
patients struggle their way to recovery.
7. Describe any skills that you were able to perform on this clinical rotation.
Aside from observing patient charts and details about their conditions and treatment, on both rotations,
we got an opportunity to interact with the patients, pick up on some of their symptoms such as aphasia,
slowed responsiveness, edema, being disoriented, etc., and hear about their individual stories. We even
helped make beds, brought breakfast to and from the patient rooms, provided other help such as
water/socks, and delivered any messages/concerns the patients expressed to the staff.
8. Appraise your own performance on this rotation.
The past two rotations were a little “passive” because of the nature of the department and lack of many
patients but it was a great way to end the year round rotations, as I could see how all the knowledge I
had gained in class and on other rotations comes together and connects in a real setting. And there was
quite a variety of things I learned- from closely diagnosing the diagnosis/ symptoms and connecting test
results to plausible outcomes, to learning about how certain medications can prove to be effective for a
wide variety of conditions, to making beds. I did pay good attention to details and changes in patient’s
test results- for example, the platelet count dropping over time, and the patient’s HTN turning into
Hypotension, finding connections between patient’s past and current medical situation. So, overall, I
tried my best and did a decent job.
Works Cited
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"Drugs & Medications - Neurontin Oral." www.webmd.com. WebMD, LLC., 2005. Web. 26 May 2014.
<http://www.webmd.com/drugs/drug-9845-Neurontin+Oral.aspx?drugid=9845&>.
"Drugs & Medications - Xarelto Oral." www.webmd.com. WebMD, LLC., 2005. Web. 26 May 2014.
<http://www.webmd.com/drugs/drug-156265-Xarelto+Oral.aspx?drugid=156265&>.
"Hypothyroidism (underactive thyroid)." www.mayoclinic.org. Mayo Foundation for Medical Education
and Research, 1998. Web. 26 May 2014. <http://www.mayoclinic.org/diseasesconditions/hypothyroidism/basics/definition/con-20021179>.
"Sjogren's syndrome." www.mayoclinic.org. ayo Foundation for Medical Education and Research, 1998.
Web. 26 May 2014. <http://www.mayoclinic.org/diseases-conditions/sjogrenssyndrome/basics/definition/con-20020275>.
Slater, Daniel I., MD. "Middle Cerebral Artery Stroke." Ed. Denise I. Campagnolo, MD.
emedicine.medscape.com. WebMD, LLC., 1994. Web. 26 May 2014.
<http://emedicine.medscape.com/article/323120-overview#a1>.