Clinical Case Scenario #1
Acute Rehabilitation Plan: Myasthenia Gravis
Michael B., a 45 year-old man, has been newly diagnosed with myasthenia gravis. He required mechanical ventilation due to respiratory failure and is now off the ventilator, but has a tracheostomy tube in place. While in acute care, the patient was fed through a nasogastric tube; however, his physician would like for him to be transitioned back to an oral diet. The patient is referred to the Rehabilitation Hospital for a multidisciplinary approach to acute rehabilitation and will be receiving physical, occupational, and speech therapy services while on this unit.
Searching in Rehabilitation Reference Center (RRC)
Using Rehabilitation Reference Center, the speech-language pathologist (SLP) searches for Myasthenia Gravis. From the Results List she chooses both Clinical Review: Myasthenia Gravis: Speech Therapy AN: 5000010661 and Clinical Review: Dysphagia: Myasthenia Gravis in Adults AN: 5000011602 to gain information about the characteristics associated with this disease as well as protocols for assessing and providing therapy to a patient with myasthenia gravis. She learns that myasthenia gravis is an autoimmune neuromuscular disease with signs and symptoms including ptosis (drooping of the upper eyelid), diplopia (double vision), neck and limb weakness, recurrent falls, dysarthria, dysphonia, and dysphagia. The rehabilitation goals are to return Michael to his prior level of functioning and independence with activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility, respiration, and swallowing.
Mr. B. is currently taking multiple medications to manage the symptoms of myasthenia gravis including an anticholinesterase, corticosteroids, an immunosuppressant, and intravenous immunoglobulin (IVIG) therapy. The therapist learns from the Medications for current illness/injury sections of the Clinical Reviews that pyridostigmine, an acetylcholine esterase inhibitor that is commonly used to treat myasthenia gravis, can cause increased salivary secretions which can interfere with speech production and swallowing function.
After discharge from the acute rehabilitation program, Michael’s wife will assist with his care at home. A thorough evaluation guided by the Examination section of the Myasthenia Gravis: Speech Therapy Clinical Review reveals that Michael has moderate dysarthria that worsens as he continues to talk. His dysarthria is marked by imprecise articulation, dysphonia, changes in pitch, and hypernasal vocal quality. The SLP searches for Dysarthria using the Rehabilitation Reference Center and selects the Clinical Review: Dysarthria, Flaccid AN: 5000009495 for additional information on assessment and treatment of this type of dysarthria. Additionally, in order to develop a tracheostomy weaning plan, the SLP searches for Passy-Muir Valve in the Rehabilitation Reference Center and from the result list chooses Clinical Review Passy-Muir Tracheostomy & Ventilator Swallowing and Speaking Valve AN: 5000010572 to further inform her evaluation of Michael’s tolerance for the valve. A swallowing evaluation informed by Clinical Review: Dysphagia: Myasthenia Gravis in Adults AN: 5000011602 reveals that Michael has mild to moderate dysphagia that becomes progressively worse over the course of the meal.
Choosing the Assessment/Plan of Care Chart and consulting with the patient and his family, the SLP devises a plan of care that includes use of the Passy-Muir Valve, speech intelligibility strategies and swallowing compensatory strategies/education designed to improve the patient’s and the patient’s wife’s understanding of myasthenia gravis as well as its impact on speech, swallowing, and respiration. As written in the Desired outcomes/Outcome measures section of the Clinical Reviews, the goals of speech therapy for this patient are to help the patient regain his ability to speak and swallow safely and independently.
The SLP returns to the Results List and chooses the Patient Education tab to print the Patient Education paper Myasthenia Gravis AN: 2009544045 for the patient and his wife to read.