The Diabetic Patient – Case Study Presentation: Amputee Case Study

Title

The Diabetic Patient - Case Study Presentation

Abstract

This presentation will explore a case study presentation of a diabetic patient who has had a right transtibial amputation. The patient history, rehabilitation and outcomes will be discussed to explore the process of amputee management. The presentation will end with references and keywords.

Key Words

Diabetes, Transtibial, mobilise, arteriosclerosis, endurance, comorbidities,

Client Characteristics

Mrs A is a 49 year old female who works full time at a food store. She is a wife and mother to 3 children, she lives in a 3 bedroom terraced house with steep stairs and no rails. She drives to work and takes her children to school. Her main physical hobby is using her static bike which she has been using 3x a week for the last 6 months. She can manage 30 minutes at a time.

She has asthma, diabetes mellitus type 2 and peripheral artery disease. She has high blood pressure and takes several medications for this and her other conditions.

Mrs A's asthma is well controlled as is her diabetes. She is very conscious of her weight, she has lost 2 stone since beginning her cycling and altered her diet.

She has a diagnosis of Peripheral Artery Disease which led to arteriosclerosis, which is a narrowing and hardening of the artery wall, this occurred mainly in the distal Anterior Fibular Artery in her right leg. A revascularisation was attempted but unfortunately was unsuccessful and left the lower part of her leg poorly vascularised.

Due to the worry of complications proximally, the patient was left with no choice but to have a right transtibial amputation. The stump length from knee to cut was 10cm. She was able to consent and have a short time to think about her decision of the amputation. This allowed some time to come to terms with this life changing surgery.

Examination Findings

Mrs A mobilised with a stick pre admission and was able to mobilise safely short distances. Mrs A also suffers from asthma and has bronchodilators which she administers independently. Mrs A’s main goal is to return to work and be able to support her family. Her main concern at this time is her pain and psychological state.
Her Activities-specific balance confidence scale came out as 48% and her Barthel score was 51/100 both suggesting low physical function.
On examination post op she was able to achieve full passive range and isometric contractions in all muscle groups.
ICF
Health Condition – right transtibial amputation
Body Functions%Structure – Mrs A has phantom sensation and pain. Her muscles are now a lot weaker and she is struggling with endurance, he rehab sessions are reduced to 10 minutes. She is struggling to feel equal and balanced despite reassurance and the use of mirrors. Her gait pattern is hugely altered due to the PPAM aid side causing a wide stance, as well as the difficulty to hip hitch and bring the PPAM aid forward to allow a step.
Activities – All daily activities have been affected. She needs assistance for things such as meal preparation, warm drinks, transfers and washing and dressing.
Participation – Mrs A is finding it difficult to participate in her normal roles as a mother and wife.
Environmental Factors – Mrs A is worried about her discharge due to the difficulties she may find at home. She's worried about her ability to work full time

Clinical Hypothesis

Mrs A's main problem is her reduced mobility. She has issues with phantom limb sensation and pain, and has had some concerns with regards to mourning her limb. However, she is well supported by family members and maintains a positive attitude throughout rehabilitation. Therefore she is more concerned with her ability to begin mobilising independently and working full time again. She is worried about her endurance and how her asthma may affect her rehab as she feels she can manage her chest but that it has become worse since admission to hospital. The risk of future complications due to her DMT2 is also a complication which could cause further issues and concerns her.

Intervention

Intial Rx:
Mrs A began her rehab programme with range of movement, stretches and static strengthening. This began with short sessions as her endurance was poor. Breathing exercises were retaught although she felt confident with her chest management. Eduction was given on desensitisation and stump management. Mobility techniques such as bridging and rolling were practised and mastered. Pivot transfers bedchair were discussed and practised as well as slide board which were less successful. ULs were strengthened with the use of theraband.

Mid Rx:
Mrs A was able to move on to standing practice with a Pneumatic Post Amputation Mobility (PPAM) aid. This allowed Mrs A to begin weight bearing and practise weight transfer and steps. Transfers were progressed to improve independence, once ULs were stronger slide board transfers became successful. ROM/strengthening was progressed to include the hydrotherapy pool and concentric exercises for both LLs. The hydrotherapy improved confidence and positivity towards future rehab and social activities.

Long Term Rx:
Her PPAM aid training progressed to her prosthetic training after her casting and fabrication. She began in the parallel bars practising balance and weight bearing with her new limb. This progressed to stepping until she was able to walk up and down the bars without assistance. ROM/strengthening continued as well as mobility pactise. Once confident she was able to begin sitstand with the leg outside of the bars.

Outcome

Mrs A is now independent with her prosthesis. She still only has a short endurance which she is aiming to improve. However, she is now able to complete activities of daily living independently. She still has some activities in which she wants to progress, such as walking without aids, cycling and returning to work.

Complications she endured are: oedema, pain and stump skin irritation. She recovered well from these problems and rehab was encouraged throughout, with the focus being on maintenance of ROM and strength when mobility was unable to be practised. This prevented more serious problems.

Her Activities-specific balance confidence scale score came out as 75% This suggests that she has a moderate level of physical functioning. Her Barthel Index score was 80 post rehab. These scores show how well Mrs A has done in improving her physical ability.

She still has some more progress to make and feels she needs to be completely independent with her mobility for short distances to go back to work. Her confidence grows continually and she has huge motivation to continue with her outpatient Physiotherapy sessions. She has now also decided to have some counselling regarding her situation. She is at home and feels she is needing some help adjusting, she remains happy with her progress but feels this will enable her to feel closure about her new life.

Discussion

Mrs A is a good example of how patients can adjust and positively manage their new situation. Mrs A has progressed very well during her time in hospital and first couple of weeks at home. She has coped well and complied with her ROM/strengthening/mobility practice both within the sessions and outside of them. This has enabled a better base to work from whilst in her physio and OT sessions. The outcome measures used have been checked for inter and intra reliability and are well trusted within the area. They have been used alongside many other interdisciplinary outcome measures such as those concerning pressure sores, healing and general post op monitoring. The joint working with occupational therapists has been very important in the process. They have worked with the patient to focus on transfers and how her home environment may need to be altered. This has been very helpful for Mrs A because this was one of her concerns when she first heard the doctors discussing the amputation. The importance of the liaising with nurses, doctors, OTs and social workers has been a huge learning curve within my first few months of my surgical rotation. The literature in this course has been of huge benefit to my management of the amputee patients and with this case in particular.

Bibliography