Case Studies

Read each vignette below. Consider whether OT evaluation or treatment is appropriate, what precautions apply, and what your session focus would be. Reflection questions are included at the end of each case.

Case Study #1

36 y/o male — GSW to posterior head & right shoulder

Patient presented as a Code Trauma activation after sustaining gunshot wounds to the posterior head and right shoulder. Per EMS, patient was seated in a car when multiple shots were fired. Initially responsive to painful stimuli with left-sided seizure activity and right-side flaccidity. Subsequently became unresponsive and developed decorticate posturing in LUE. Intubated in the field. Sutures placed for head entry/exit wounds; EVD placed; mannitol administered for swelling. Extubated on HD 5.

Imaging

  • CT head: occipital lobe trajectory to right frontal lobe passing through left lateral ventricle; intracranial bullet and skull fragments with SAH and IVH
  • Right posterior trapezius bullet wound with fragment adjacent to clavicle with hematoma
  • Bullet tracked L posterior to R anterior; multiple shrapnel and skull fragments along trajectory; main projectile remains intracranial; extensive hemorrhage along bullet track

Current Exam & Status (HD 7)

  • Opens eyes to stimulation; does not regard or track; left gaze preference
  • LUE/LLE intermittently following commands (squeeze fingers, wiggle toes); no purposeful RUE or RLE movement
  • + cough; + L corneal; weak R corneal; no gag
  • Intermittently following commands — smiling, weak L hand grasp, wiggling L toes
  • Withdrawing RUE; triple flex RLE
  • + R facial droop; no speech

Clinical Data

  • EVD open at 5 with serosanguinous output
  • ICP <20
  • Daily TCDs: uptrending HD 6, stable/downtrending HD 7
  • SBP goal <200; Nicardipine PRN
  • Lines: EVD, arterial line

Reflection Questions

  1. Is this patient appropriate for OT evaluation? What factors support or give you pause?
  2. What precautions are most relevant here? How would the EVD, ICP, and BP parameters affect your session?
  3. How would you assess for command following in a patient with no speech, a right facial droop, and only intermittent responses?
  4. What would your evaluation focus on? What standardized tools might you use?
  5. Given the motor presentation (purposeful LUE/LLE, withdrawal/triple flex on right), what early treatment activities are appropriate?
  6. What would a realistic short-term goal look like for this patient?

Case Study #2

77 y/o male — left frontoparietal IPH with IVH, worsening hydrocephalus

Patient with PMH significant for Afib (on apixaban) and prior stroke (residual Wernicke's fluent aphasia) presented as an OSH transfer after being found down (LSW noon) with left frontoparietal IPH, IVH, worsening hydrocephalus, and midline shift. Status post EVD placement on HD 5 and intubation for worsening mental and respiratory status. Course complicated by ongoing fevers, hospital-acquired pneumonia, UTI, seizures (now on levetiracetam 1000 mg BID), and labile BP. EVD discontinued on HD 14.

Current Exam & Status (HD 15)

  • Vent mode: PS/CPAP; FiO₂ 30%
  • SBP goal <160; SpO₂ goal >88%
  • Occasional spontaneous movement in LUE/LLE
  • Opens eyes for short periods to stimulation and pain; not fixating; blink to threat on L but not R
  • No command following
  • Amantadine 200 mg BID

Reflection Questions

  1. Is this patient appropriate for OT? What does the current exam tell you about his level of consciousness?
  2. What confounders are present that may be suppressing his level of responsiveness?
  3. How does the prior history of stroke and Wernicke's aphasia affect your evaluation approach?
  4. What does the asymmetric visual response (blink to threat L but not R) suggest, and how does it influence your positioning and stimulation strategy?
  5. The patient is on amantadine — what is its purpose in this context, and how might it affect your session timing?
  6. What sensory stimulation strategies would you prioritize, and how would you involve the family?

Case Study #3

67 y/o male — L M2 occlusion s/p tPA, intubated, aspiration PNA

Patient with PMH significant for prior COVID-19 (complicated by PE), ESRD (previously on hemodialysis), Afib and Factor V Leiden (on warfarin), and recent hospitalization for staph epi bacteremia presented as an OSH transfer status post intubation for acute right-sided weakness and aphasia. tPA administered on arrival. Found to have L M2 occlusion; not an IAT candidate. Course complicated by likely endocarditis secondary to mitral valve abscess vs. caseous annular calcification (on meropenem) and aspiration pneumonia. Surveillance CT shows new infarcts — possible right thalamus and right occipital lobe. Exam clouded by sedation.

Current Exam & Status (HD 4)

  • Vent mode: AC/VC with PEEP 12
  • Desaturates significantly with repositioning and bed mobility
  • Requires fentanyl bolus for repositioning
  • SBP above goal; trending 140s–160s
  • Opens eyes to stimuli; localizing with LUE
  • No RUE movement; withdraws LLE; triple flex RLE
  • No command following

Reflection Questions

  1. What are the primary safety considerations before initiating this session? Which are most immediately limiting?
  2. The patient desaturates with repositioning and requires fentanyl for movement — how does this affect what you can realistically do in a session?
  3. New infarcts are suspected in the right thalamus and right occipital lobe. What deficits might you anticipate, and how would you assess for them?
  4. The exam is "clouded by sedation" — how do you differentiate sedation effects from true neurological impairment in your assessment?
  5. The patient has aphasia combined with intubation. How does this affect your communication strategy?
  6. What would you communicate to the team after this session, and what would you document?