Question

Mr. Cooper is a 73-year-old man with no significant past medical history. He lives alone and is very independent in function and spirit. He was seen in the emergency department six weeks ago for complaints of “arthritis in his right knee.” He was examined, given a prescription for ibuprofen, provided with a cane, and instructed to follow up with his health care provider. When Mr. Cooper sees his health care provider for his follow-up visit, the health care provider notices that as Mr. Cooper enters the examination room, he has right footdrop. When the health care provider asks Mr. Cooper what has brought him in today, Mr. Cooper states “I have arthritis in this right knee.” Mr. Cooper explains that he has had this “arthritis” for three months. However, when asked about pain in the knee, Mr. Cooper denies any pain and states “well, maybe it’s a nerve problem.” On physical exam, his vital signs are within normal limits and consistent with Mr. Cooper’s baseline. The health care provider notes that Mr. Cooper has no strength or power in his right lower extremity from the knee down. There is increased tone in his upper right extremity, indicating that those muscles are tighter than they should be. The health care provider also notices hyperreflexia. The health care provider prescribes a head computed tomography (CT) scan and multiple blood tests. The results of the CT scan and blood tests are all within normal limits. An urgent referral to a neurologist is made, and the health care provider asks the nurse to arrange for Mr. Cooper to have magnetic resonance imagery (MRI) of his head and neck and an electromyelogram (EMG). The nurse plans to arrange dates for these tests and to call Mr. Cooper with instructions. Mr. Cooper is fitted for an ankle-foot orthosis (AFO) brace and home physical therapy is arranged as prescribed by the health care provider.

Case Study

The nurse attempts to notify Mr. Cooper of the dates, times, and instructions regarding his MRI and EMG. However, Mr. Cooper does not have an answering machine. The health care provider is notified and she decides to call Mr. Cooper from home to see if she can reach him at home and give him the information. When the health care provider calls Mr. Cooper, he is speaking with slurred speech. The health care provider asks Mr. Cooper how long he has had difficulty speaking clearly to which Mr. Cooper replies, “I just have a touch of laryngitis is all.” Mr. Cooper denies a cough, runny nose, fever, discomfort in his throat, and dysphagia. Concerned, the health care provider suggests that Mr. Cooper go to the emergency department for an evaluation. Despite the health care provider’s repeated suggestions, Mr. Cooper refuses. The next day, the health care provider calls Mr. Cooper’s home physical therapist and asks the therapist to call her during the visit and let her know if Mr. Cooper is still exhibiting slurred speech. Later that morning, the physical therapist notifies the health care provider that indeed Mr. Cooper continues to have slurred speech. Per the health care provider’s request, Mr. Cooper is transported to the emergency department. An MRI is unrevealing. However, an EMG is consistent with amyotrophic lateral sclerosis (ALS).

Questions

Mr. Cooper, who is with his daughter, asks the nurse “What is ALS? Is it a type of arthritis like I thought?” It can be a sad and emotionally difficult explanation to give, but how would you explain the diagnosis to Mr. Cooper? Include in your discussion the symptoms, cause, incidence, and usual age of onset.

What is the prognosis for Mr. Cooper?

An occupational therapist will work with Mr. Cooper to help him with strategies to maintain his independence with activities of daily living (ADLs) for as long as possible. Discuss at least five pieces of equipment available to assist Mr. Cooper with his ADLs.

Why do you think Mr. Cooper self-diagnosed himself with “arthritis” and “laryngitis”?

Answer 1

1)ALS :- amyotrophic lateral sclerosis. It is not arthritis , it is a progressive neurodegenerative disease, effecting the neurons, and the lost neurons are replaced by gliosis. Usually the onset of disease is between 49 to 70 years, but usually they come for treatment later so diagnosed a little later. it will lead to weakness of muscle as well as muscle atrophy, muscle disability and respiratory failure or any other pulmonary complications leading to death.

2) the prognosis of the disease is very poor , usually the individual lives for two to five years and may extend to 10 years

3) ALS therapy equipment

- power wheel chair: this helps the patient to move independantly, also will aid in there mental stress relief, like visiting a park or moving around the house, rather being on the bed.

-respiratory aids: essential when respiratory muscles are effected, there are number of technology including breathing pacemaker are available, invasive and non invasive aids are also available.

- SGD devices: speeches generating devices, this system have sign language, sign or picture boards with preformed speech.

-eye gaze devices: used when SGD devices are no longer useful, for using this device at least upper, lower and lateral eye movements are to be preserved, here the eye movements are used to activate letter or phrase in a computer.

4) Muscle weakness of leg he thought it was due to some knee joint pathology

He was having slurred speech he diagnosed it to be due to some throat infection.