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Case Study Presentation

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by

lissie salinas

on 1 December 2015

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Transcript of Case Study Presentation

61 y/o male
Hypertension
Chronic Lumbar Tightness
1980: Torn meniscus and ACL
Degenerated L5 disk
Degenerative joint disease in bilateral knees
Pain in bilateral LE for four years
Weakness and burning in right leg
Currently taking prescribed pain medication when needed
April 2015: Stem cell surgery, taken from hip and introduced to both knees
History
Case Study Presentation
Performing heavy duties around the home
Can no longer hop, run or make sharp turns
Standing for longer than ten minutes
Sitting for longer than ten minutes
Walking on uneven ground
Walking up or down stairs
Sleeping the entire night (due to pain)
Limitations:
5/15 degrees R knee extension
110/130 degrees R knee flexion
12/15 degrees L knee extension
105/130 degrees L knee flexion
Lumbar strength (MMT) 4/5
Left knee strength (MMT) 4/5
Right knee strength (MMT) 3/5
Poor sensation to light touch bilateral legs
Unable to squat, climb stairs, or stand for long periods of time
Can no longer play golf various times a week, must be very cautious
Current Level of Function
Drop foot (left)
Sharp pain, sudden onset
Mild edema on left knee
Slightly antalgic gait
Decrease mobility of bilateral patellofemoral joints
Decreased strength of trunk and bilateral knees
Symptoms:
Unrestricted!
Played gold 3-4 times a week with no difficult
Walked one mile with no difficulty
Prior Level of Function
Compressed Disk (L5) causing radiculopathy down R leg
Previously treated with physical therapy, but symptoms acutely arose and is now being treated for low back pain
Comorbidities
Patient will increase ROM in bilateral knees from 5-10 degrees in 10 days.
Patient will be independent with home exercise program in 3 days.
Patient will become educated on the appropriate technique to use when doing exercises as well as any precautions to increase his compliance and confidence in the therapy program
Patient will decrease amount of pain felt in the bilateral LE by two measures on the pain rating scale
Patient will reduce amount of edema by 5cm. in 10 days
Patient will maintain cardiovascular endurance throughout the therapy program
Patient will maintain strength of the unaffected areas
Patient will ambulate with normalized gait pattern independently in 21 days.
Patient will be able to ascend/descend stairs without pain in 21 days.
Patient will increase each MMT grade by one number in 21 days.
Patient will be able to stand for 30 min 21 days.
Patient will be able to sit for 30 min. in 21 days.
Long-Term Goals:
Lissie Salinas
Short-Term Goals:
Modalities:
Manual soft tissue extension in knee (10 minutes each session)
Joint mobilization in knee and lumbar region (10 minutes each session)
E-Stim device to be used at home (30 minutes once daily or used to assist in managing pain
Progression
Patient concinues to make progress and has achieved 50% of goals.
Balance has improved.
Gait has become normal and transfers between legs without any pain.
Patient has increase strength in bilateral knees by one grade.
Prognosis/Return to Activity
Patient is keeping up with home exercises and continues to improve. Patient has been able to slowly return to his previous level of activity, and shows excellent rehab potential.
My Personal Statement
Being able to go into each clinic and take in the different situations each setting has provided has been an amazing learning experience. I thoroughly enjoy walking in and seeing what each day brings and am ecstatic to have found such an exceptional field to study in. This course has also taught me a valuable lesson in professionalism as well as helped me during my studies at Incarnate Word.

Things I have Learned or Acquired from Experience
I have learned that the physical therapy field is one where you must learn your studies to a tee in order to adapt to the different situations each patient may bring. No two people are alike, and because of that, a physical therapist must be able to understand every aspect of an injury and plan according to each patient's needs
Meet Fred!
Thank You
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