Posterior Fossa Syndrome

Inpatient Rehab

Nursing Evaluation

7 yo female admitted for intensive inpatient rehabilitation. Has been receiving outpatient PT, ST, OT for decreased muscle tone, impaired balance and movement control secondary to a posterior fossa mass.

PMH: patient was sent home and now readmitted for inpatient rehab along with chemotherapy.

Allergies: developed a rash to penicillin.

Medications:

Prevacid: gastro-esophageal reflux disorder
Bactrim: antibiotic
Ativan: anxiety, nausea & vomiting related to chemotherapy
Lidocaine: local anesthesia, ventricular arrhythmia
Mylicon drops: flatulence.

Vital signs: afebrile, blood pressure 94-100/58-63, pulse 100, respiratory rate 18-24 per minute.

Chest, coronary, abdomen, extremities: unremarkable.
Neurologic: irritable, crying spells, responds to verbal commands 50% of the time, worked on sitting balance.
Impression: posterior fossa syndrome with impaired gait, balance, muscle control, and speech.

Plan: continued to work on intensive therapies, including improving mobility, gait, balance, transfers, self care skills, verbalizing wants and needs, and oral motor control. Patient will most likely remain on the unit for approximately 3 weeks. Start chemotherapy; plan for dietary modification.

Emotional needs: rehab counselor referral.

Prognosis: good.

Discharge Summary

Hospital course: patient has been receiving outpatient therapy but a trial of inpatient rehab was attempted to progress patient faster. Patient’s therapy included PT, ST, and OT and some radiation therapy. Due to difficulty with scheduling, the family thought it was best to be transferred home and resume outpatient physical therapy.

Physical Exam

Vitals: afebrile, blood pressure 93/63, pulse 112, respiratory rate 20 per minute.

HEENT, chest, coronary, abdomen, extremities: unremarkable.

Rehab: patient showed no initiation of left arm use. Required trunk support for standing, dependent for weight shifting during ambulation.

Psychosocial: parents worked on recreational activities for the child. Also was seen by Child Life Services to work on recreational therapies.
Started her chemotherapy prior to discharge home.