Assignment #1: Screening
Instructions: Assignment #1: Using the Documentation Template from the Guide to Physical Therapist Practice (See Handouts), complete a history and systems review on a volunteer subject. Submit the completed forms and a 1-2 page summary of the results including any findings that would indicate a need for referral to another health care provider. NOTE: Do NOT use the subject’s actual name, address, or any other confidential identifier. Use the Inpatient Form if your volunteer subject is an inpatient OR the Outpatient From if your volunteer is an outpatient. The Systems Review Form is used for both in-patient and out-patient subjects. Save the forms completed by hand as a pdf. Be sure YOUR NAME is on every page you submit.
For assignment 1, make copies of the history and systems review from the Guide to PT Practice (see Handouts section), complete them by hand, scan them and save them in pdf format for submission. Any volunteer subject can be used for that assignment. They do not have to be an actual physical therapy patient. All assignments are to be word processed; 12 point font and double spaced are preferred. Other than the forms for Assignment #1, handwritten assignments will not be accepted. Do not use color, pictures, etc. in your documents. Use only black text. Number the pages and make sure your name is on every page.
Attaching the inpatient and outpatient form and system review form depending which one you want to use. Select total knee replacement case if selecting inpatient form.
The patient is a 39-year-old single female of African American descent and an elementary school teacher with a college education. She lives alone in a private apartment with an elevator, is a reformed smoker who quit 4 years ago and a social drinker. An Advanced Practicing Nurse referred the patient to us. She is generally in good health. The father had a stroke in his late fifties; so this patient is genetically predisposed to high blood pressure and diabetes.
She presented with a sprained ankle and difficulty in walking or standing for prolonged periods of time, which occurred 3 months ago. She also presented with a high blood pressure of 180/100 mmhg and a weight of 200 lbs on a 5’6 frame.
The sprained ankle was sustained during her morning power walk, which is an exercise routine she does twice a week. Patient also complained that she was unable to stand on the leg for long periods of time and this was having a negative effect on her job, as she is an elementary school teacher and moving about in class was extremely difficult. The patient’s excess weight exacerbated the situation as it placed further strain on the already compromised ankle.
Before coming to see the physiotherapist 3 months after the incident, the patient had tried to manage the sprained ankle at home by keeping her weight off the leg and applying a warm towel compress on the painful and tender ankle in an effort to reduce the pain, which only exacerbated the situation. This procedure for early ankle sprain management was contradicted by Tiemstra (2012), who clearly stated that early mobilization speeds healing and reduces pain more effectively than prolonged rest. Also, contrary to common believe that lower levels of activity in obese patients may make them less susceptible to injury than normal-weight individuals, studies have shown that strains, sprains and dislocations are actually more common in this vulnerable population (King, 2013).
Diagnosis was then established as a strained ankle in an overweight hypertensive woman with impaired joint mobility and a limited range of motion, associated with localized inflammation.
The patient presented with a BMI of 32.3, where a BMI above 30 is an indication of obesity. The fact that she was overweight and hypertensive were indicators that she needed further investigation and follow up. She was therefore referred to a Primary Health Care Physician for proper management.
Patient management, which includes anticipated outcomes, expected outcomes, interventions, patient education and discharge plans can be located in the patient’s chart.
KING, C. (2013). The influence of Obesity on Ankle Fracture Risk. Lower Extremity Review. Retrieved from Lower Extremity Review website, http://lermagazine.com/article/the-influence-of-obesity-on-ankle-fracture-risk.
TIEMSTRA, J. D. (2012). Update on Acute Ankle Strains. American Family Physician, 85(12), 1170-1176.
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