The following are four sample patients requiring physical therapy.

Study the information for each patient and make suggestions from the list of treatments

Patient Case 1 – Primary Diagnosis: CVA  ( cerebrovascular accident)

The patient is a 73 year old female who is 2 weeks post left (L) CVA and is a resident in the SNF (skilled nursing facility).  Current problems include:

1. Right (R) shoulder subluxation with pain due to decreased muscle tone
2. Decreased R-sided strength
3. Lack of normal mobility and inability to perform functional ADLs
4. Fluctuating high blood pressure and episodes of dizziness during past treatment sessions.

PMH (past medical history): 

1. Hypertension
2. Diabetes
3. s/p left modified radical mastectomy 10 years ago with residual left UE (upper extremity) lymphedema. Edema is currently under control with use of a compression garment. 
4. Urge incontinence.

Social history: Patient is married x 50 years. Her husband is in good health and will be able to help at home. She has three children. Two live in town; she is estranged from the son that lives out of town. She lives in a 50 year old ranch style house that has a finished basement where her laundry and sewing room are located.

Evaluation:

• Tone: Minimal tone in R UE (previously flaccid)
• ROM: PROM R shoulder is 0-110 degrees of flexion and 0-90 degrees abduction; L UE and LE are WNL (within normal limits)
• Strength: R LE strength - hip flexion, abduction and adduction; knee flexion and extension; and ankle DF varies from 2+ to 3/5. Mild extension synergy noted with movement of R LE; L UE and L LE grossly 4/5 throughout. 
• Function: sitting at the edge of the bed requires moderate support; elimination of support results in leaning to R. Dynamic sitting balance results in balance loss to R side and posterior requiring max assistance to recover. Head control in sitting is good.
• Transfers and bed mobility: supine <-> stand: Moderate assist of 1. Bed mobility requires minimal assist of 1 and ongoing verbal cues
• Ambulation: Stands with moderate assist x1. Unable to maintain dynamic standing balance for gait without max assist
• R sided neglect – requires verbal cues to locate R UE/LE.
• Due to her decreased mobility, she has been identified as having functional incontinence. 

Patient Goals:

1. Resume walking
2. Resume sewing and cooking
3. Walk down the aisle at granddaughter’s wedding in 3 months

STGs:  Pt will achieve the following in 2 weeks:

1. Independent bed mobility to reduce risk of skin breakdown.
2. Sit at side of treatment mat with feet flat on floor with light support of therapy ball  against back (min assist) 2 mins for increased participation in ADLs
3. Sit<-> stand min assist x1 to promote circulation and prepare for ambulation.
4. Initiate assisted ambulation for proprioceptive training
5. Passive R shoulder ROM increase by 20 degrees to decrease L shoulder pain, especially during dressing and other ADLs
6. Increase R sided strength to at least 3+/5 in to facilitate mobility and functional ADLs

Plan of Care (4 treatments)

Patient Case 2 – Primary Diagnosis: Spinal Cord Injury with Paraplegia

A 22 year old athletic male is admitted 2 weeks post spine fracture to inpatient rehab. The patient sustained a complete T12 spinal cord injury in a MVA (motor vehicle accident). Patient underwent spinal stabilization surgery and treatment for internal injuries sustained during the accident. During the past two weeks of acute care, he has had physical therapy interventions, including ROM to the extremities and limited bed mobility in his room.  Today is the first time his has come to the rehab gym for treatment.

PMH: No significant injuries or diseases in PMH other than recurrent upper respiratory infections. 

Social History: Patient is a senior in college. Career goals are not established. He has a supportive family and, after recovering from a period of anger and depression, demonstrated initiative to improve his function in acute care.

Evaluation:

• Complete loss of sensation and motor control below the level of T12.
• Tone: Mild spasticity of bilateral LE
• ROM: WNL with following exceptions: SLR = 0-60 degrees bilaterally; Shoulder extension = 0-30 degrees bilaterally; Wrist extension = 0-60 degrees bilaterally
• MMT (manual muscle testing) Bilateral UE’s for shoulder flexion, extension, ER/IR, elbow flexion and extension 4/5.  Wrist flexion and extension 3+/5 and grip strength WNL’s bilaterally.
• Transfers and Bed Mobility:
  • Rolls in bed with min assist of one to stabilize surgical site
  • Supine to sitting on edge of bed is mod assist to position lower extremities and stabilize surgical site
  • Patient can sit on edge of bed with arm support with minimum assistance for safety; Patient fatigues in 30 seconds or less
  • Bed to W/C (wheel chair) transfer  with sliding board and min assist of one; W/C to bed transfer with sliding board and mod assist of one
• W/C ambulation is slow, but independent on indoor level surfaces

Patient’s short term goal is to be independent in community ambulation with an adapted wheelchair and independent in all hygiene ADLs. Patient is still formulating long term goals, which include participation in W/C athletics, completion of college degree, and independent driving.

STGs:  Pt will achieve the following in 2 weeks:

1. Independent rolling
2. Independent sitting for minimum of  5 min. for independence  in grooming ADLs
3. Independent sliding board transfer mat<-> w/c. Min assist pivot transfer
4. Increase shoulder ext ROM to 65 degrees for improved wheel chair propulsion; wrist extension to 90 degrees and hamstring flexibility to 90 degrees bilaterally for increased mobility for functional ADLs
5. Independent pressure relief strategies
6. Return upper extremity strength to 5/5 for maximum independence in functional ADLs
7. Independent W/C on all surfaces except curbs

Plan of Care (4 treatments)

Patient  Problem 3 – Total Hip Replacement with Cardiac Complications

The patient is a 69 year old female who had a R total hip replacement 5 days ago. After surgery, she had cardiac arrhythmias and all rehabilitation for the surgery was placed on hold until her cardiac system stabilized. She spent 2 days in ICU followed by 3 days in the cardiac unit of the hospital. She was transferred to the transitional care unit this morning. She has been sitting up in bed on the nursing unit, but has not been out of bed yet.

PMH: Patient has history of MI (myocardial infarction) 3 years ago. She has been stable with medication. Nursing notes indicate that BP has remained lower than normal since surgery. She has osteoarthritis and has been told she will also need a total knee replacement on the left side. She is moderately obese.

Social history: Patient is widowed and has lived alone for the past 2 years. She has no family in the area, although she can depend on several close friends for assistance. She was previously active walking 2-3 miles per day on level until the pain became too severe approximately 6 months ago. She must be able to negotiate stairs and walk at least 30 feet to return home.

Evaluation:

• Upper extremity ROM is normal except shoulder flexion and abduction, which are 0-120 degrees bilaterally secondary to arthritis. L LE ROM is WNL except L knee ROM lacks 5 degrees to reach full extension and flexion is limited to 100 degrees. ROM of R ankle is WNL; knee lacks 5 degrees extension to 120 degrees flexion; hip ROM deferred.
• Strength of the upper extremities are WNL within available ROM. L LE strength is normal, except hip flexion is 3+/5 and hip extension and abduction are 4/5. R ankle strength is 5/5. Patient cannot lift R leg independently. R hip and knee strength testing deferred.
• Sensation is intact to light touch. Reflexes are normal.
• R hip is edematous and painful to touch consistent with recent surgery.
• Patient requires moderate assistance of two for bed mobility, rise to sitting on edge of bed, and transfer to a w/c.
• Patient requires minimal assist of two for ambulating short distances in the parallel bars – one to assist with placement of R foot and one to assure safety. Patient with decreased proprioception of R LE, and demonstrated significant improvement after ambulating 10 ft x 3.  Patient is allowed PWB on R and is having difficulty with reduced weight bearing.
• Vital signs return to normal within 3 minutes of rest.

Patient goals:

1. Gain sufficient mobility to return home, including gait on stairs.
2. Independent ambulation on uneven surfaces so she can walk to garden.

STGs:  Pt will achieve the following in 2 weeks:

1. Independent bed mobility
2. Independent transfers
3. Independent ambulation with walker PWB (partial weight bearing) R on level
4. Independent ambulation with crutches or cane and rail on stairs
5. 5/5 strength of L LE for achieving functional ambulation at home
6. Independent home exercise program

Plan of Care (5 treatments)

Patient Problem 4 – Total Knee Replacement with TBI and Cardiovascular/Pulmonary Complications

The patient is a 62 year old male who is 4 weeks s/p L TKA (total knee arthroplasty).  After 3 days of inpatient care, he was discharged to home. Within the first 24 hours of being home, he fell down the stairs to the basement resulting in a TBI (traumatic brain injury).  He is now in subacute rehab.

PMH: significant for COPD and history of smoking 1 pack/day for 40 years, HTN (hypertension) and diabetes. 

Social History: Pt lives with his wife of 35 years.  He is recently retired, but his wife still works full-time. They have 1 daughter and 1 son, both of whom live out of town and they enjoy traveling frequently to visit their family. The patient lives in a ranch style home with 2 steps to enter and 10 steps into the basement.

Evaluation:

• Pt is currently classified as Rancho Los Amigos Level VII and is able to focus on rehab for short periods of time but is easily distractible.
• Pt has L knee AROM 12-103 degrees. All other ROM is WNL (within normal limits).
• LE strength varies from 3+ to 4/5 in both R and L lower extremities. Upper extremity strength is grossly 4/5 throughout.
• Patient’s sensation to light touch, pressure, and temperature are intact.  Decreased proprioception and kinesthesia in bilateral upper and lower extremities. 
• Mild deficits in motor control of the trunk requiring minimum assistance of one for sitting balance when sitting on the edge of the mat.
• Pt is independent with bridging and bed mobility. 
• Minimum assistance of one required for sit <-> stand transfers. Poor standing balance with moderate assistance of one for static standing. 
• Pt ambulates PWB 50 feet with FWW (family welfare worker) and minimal assistance of one to stabilize balance. Pt requires verbal cues and moderate assistance for ascending/descending stairs due to poor attention to safety.

Patient goals: Patient wants to be independent in walking on all surfaces. He wants to return to mowing using a riding lawn mower, hunting, and fishing.

STGs (short term goals):  Pt will achieve the following in 2 weeks:

1. Sit at edge of mat independently for 5 min without loss of balance.
2. Independent sit to stand transfers
3. Independent dynamic seated weight shifting for 1 min as needed for ADLs
4. Ambulation PWB 100 ft with wheeled walker on level and rail and cane on stairs with stand by supervision for safety
5. Independent static standing for 1 min with stand by supervision for safety
6. Increase L knee AROM to 0-130 degrees for normal gait and ADLs
7. Increase strength to 4+/5 throughout

Plan of Care (5 treatments)

List of Possible Interventions:

1. Balance activities in all postures
2. Bed mobility training
3. Functional training to improve bed mobility; posture transitions, and gait
4. Gait training on level and stairs PWB R
5. Gait training PWB with wheeled walker; stair training
6. Instruction in pressure relief on all surfaces
7. Mobility training to include rolling, posture changes, transfers, and W/C mobility on all surfaces
8. O2 saturation not to go below 92%
9. Patient education
10. Patient instruction in post-op hip precautions and safety
11. Patient/caregiver education on home preparation and exercise
12. Patient/caregiver education on spinal cord injury and care
13. Therapeutic exercise for flexibility and strengthening
14. Therapeutic exercise for increasing L knee AROM, strength, and balance in all postures
15. Therapeutic exercise for strengthening all extremities, including R hip; and ROM of R hip
16. Therapeutic exercises, including activities to increase R shoulder ROM; strengthening of R side
17. Transfer training

Pt 1: 1,3,11,16; Pt 2: 6,7,12,13; Pt 3: 2,4,10,15,17 ; Pt 4: 5,8,9,14,17