impairments which restricted his participation in his usual social activities. Systems review (PT Guide version) ● Musculoskeletal system : impaired based upon the patient’s report of LBP and lower extremity symptoms. This area will be examined further during the objective examination. ● Cardiovascular/respiratory system : not impaired based upon a blood pressure of 115/75, a heart rate of 75, a respiratory rate of 14 and the absence of peripheral edema. ● Neuromuscular system : impaired based upon the presence of a mildly antalgic gait and unsteady transfers from sitting to standing and back. The patient’s gait and transfers will be evaluated further during the objective exam. ● Integumentary system : not impaired based upon observation by the therapist and patient denial of any skin problems. ● Communication ability : not impaired based upon observation and interaction with patient by the therapist. The patient’s affect, cognition, and learning style appeared to be intact and the patient did not use any assistive devices (e.g. glasses, hearing aid). Due to the presence of ibuprofen, the patient was asked about gastrointestinal distress, which he denied. Ken reported no problems with bowel/bladder control. He denied alcohol abuse, smoking tobacco, or illicit/recreational drug use. Prescription medications The patient denied use of prescription medications, supplements, and over-the-counter medications except for the use of ibuprofen for his LBP. History and status of current condition The patient’s chief complaint was intermittent and variable right- sided LBP with radiation of the pain into the right posterior thigh down to the knee. The pain was described as deep, achy, and poorly localized. The patient reported an insidious onset of LBP that began about 3 months ago. The posterior thigh pain began about 1 month ago. The patient was asked to rate his pain on a scale of 0 to 10. He reported the intensity of his LBP was 2 to 4/10 at onset but is now 5 to 7/10, with his lower extremity symptoms rated as 4 to 6/10. His symptoms were aggravated with coughing/sneezing, prolonged walking, sitting greater than 15 minutes, and lying supine. He reported his symptoms were eased with the use of hot packs applied to the low back. Though he has greatly reduced his physical activity and avoided aggravating activities, his LBP has gotten worse over the last 3 months. Ibuprofen helped to control, but not eliminate, the LBP and radiating symptoms. He reported his symptoms were Subjective examination Bob is a 68-year-old male with a 10-year history of intermittent and variable left hip pain who was referred to the clinic. Four years after the patient first reported hip pain, his orthopedic physician informed him that he had hip osteoarthritis based on radiographic findings. The left lateral hip pain has gotten progressively worse over the 10-year time period. The patient’s chief complaint at the time of evaluation was left lateral hip pain that was aggravated with transitioning in and out of the car, ascending and descending a flight of stairs, and walking approximately 0.75 miles with the use of an assistive device. He denied smoking tobacco, use of illicit/recreational drugs, or Bob reported that his medical history included a kidney transplant 12 years ago. His physician stated that his renal failure was probably due to the patient’s poorly controlled hypertension. He requires medication to prevent rejection of the transplanted kidney. Bob reported taking three different medications each day for his hypertension. He has an 8-year history of gout that is controlled currently with medication. He reported taking medication to prevent “bone disease” and abuse of alcohol. Medical history
the worst at night when he laid down, especially in the supine position. His pain resulted in significant difficulty sleeping; i.e. the pain awakened him from sleep most nights. He reported that during the last month a change in position provided minimal relief and did not allow him to go back to sleep most nights. All of the general health questions were answered negatively except that the patient reported losing 10 pounds in the last 3 months without a change in diet. Questions 1. Which of the patient’s symptoms appear to be mechanical in nature? 2. Which of the patient’s symptoms appear to be non- mechanical in nature? 3. How would you manage this situation: treat, treat and refer, or simply refer the patient back to his physician? Answers 1. a. The patient’s description of the LBP and lower extremity pain were consistent with a somatic problem and mechanical in nature. b. The patient’s LBP and referred pain were aggravated with sitting and coughing/sneezing. c. The patient’s chief complaint was LBP that was intermittent and variable. (Many, but not all visceral disorders, produce constant pain.) 2. a. The patient’s most intense pain was at night. b. The patient was awoken regularly from sleep by LBP. c. The patient did not find relief from night pain with a change in position. d. Bed rest (lying supine) did not provide relief and increased his symptoms. e. The patient reduced his physical activity and avoided aggravating activities (conservative therapy), but his LBP has gotten worse over the last 3 months. f. The patient reported the unintended loss of 10 pounds in 3 months. g. The patient is over 50 years old and has undiagnosed LBP. 3. This patient should be referred to his physician for further evaluation based upon the presence of multiple findings consistent with a visceral disorder. Conservative treatment could be initiated, but the therapist must proceed with caution until the patient has further work up to determine the etiology of his LBP.
CASE STUDY 2: MEDICATION AND POLYPHARMACY CASE
hypocalcemia. The patient did not report other comorbidities or other surgeries and denied other medical problems. The patient lived independently in a single story house with his wife. The patient enjoyed outings with his friends and hoped to golf with them again soon. These activities were currently limited by his impairments and restricted his participation in social activities he previously enjoyed. Systems review (PT Guide version) ● Musculoskeletal system : impaired by the patient’s complaints of pain and the observed lack of range of motion in his hip. This area will be examined further during the objective examination. ● Cardiovascular/respiratory system : impaired due to the presence of hypertension for which he reported taking three medications. His resting blood pressure was 142/86 with a resting heart rate of 72 beats per minute. The therapist will consider the impairments in the cardiovascular system in the design of the exercise program for this individual. ● Neuromuscular system : impaired based upon observation of the patient’s antalgic gait and reports of increasing difficulty with transfers. This area will be examined further during the objective examination.
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