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Mastering Functional Reporting Case Scenarios

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High Level Case Scenario

She is a 71 y/o female with history of resolved bilateral rotator cuff impingement and low back pain over the past 5 years and a slow progressive increase in knee pain over the past year. Her general health is excellent with no other medical issues. Prior to this severe knee pain she was completely independent and was taking dancing lessons. Now she cannot even go up one step with her sore knee. Her goal is to be pain free and return to doing all she did before

FINDINGS

Pain

• On a scale of 0-‐1, the pain varies from 3-‐10

Strength

• Knee Extension: R= 38#, L= 26# (Norm 50#)

• Hip Abduction: R= 38#, L= 26# (Norm 34#)

• Plantarflexion: 4/5 able to do 5 reps (Norm 25)

o Daniels and Worthingham Muscle Testing; 2014; Hislop

§ Grade 5 = 25 times

§ Grade 4 = 2-‐24

§ Grade 3 = 1 rise

§ Grade 2 = ROM – NWB with resistance

§ Grade 1 = Trace

§ Grade 0 = no palpable contraction

• OLST: R-‐1, L=0-‐ Less than 5 risk for falls (Norm 14 seconds)

• ROM: WNL except Left knee 0-‐109 degrees

Functional Test: LEFS is below



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Mid-‐level Case – Information supplied by daughter

Pertinent Medical History – Compression fracture noted as T7, and tendonitis in back of ankle/calf. Activity level prior to this current episode – very active, member/officer of several organizations. Went out to dinner at least 1/week, did all own driving, shopping, etc. – completely independent.

History of this current issue – Compression fracture occurred about a month ago. Dr. at first misdiagnosed as muscle strain due to coughing from bronchitis/pneumonia.

Current Problems – Backache at times. Pain from tendonitis. Takes occasional codeine. Takes Advil everyday and uses Lidocaine patch many days.

What she would like to be able to do – Have energy. Get rid of pain. Resume old schedule and activities.

Any questions she has for me – none so far

Anything else you think I should know – no one would ever have guessed my mom’s age before. She is more independent than many people 20 years younger than she is, and that kept her young. This has limited her activity and her social life and she needs to get those back.

Mid-‐level Case – Letter to Physician

Dear Dr. K,

I had the pleasure of meeting and working with Ms. X on June 17th. At that time she revealed a history of a compression fracture 5 weeks ago that is slowly getting better. She says her pain ranges from a 4-‐10 and today it may be even less (an aching of a 3). She says standing for long periods tends to make it worse. She continues to take less medicine for pain relief and is now taking 4, 200 mg Advil and an occasional lidocaine patch and ½ of a codeine pill.

Her main functional complaint is tiredness, no energy, pain and she is afraid to lift anything. We conducted several functional tests and her results are below.

1. Timed Up and Go: She scored 10 seconds-‐ Norm for her age is 7.8. This score is low and reflects her lack of endurance.

2. Sit to Stands: She was able to do 5 sit to stands in 16 seconds which correlates with a decreased risk of falls, however next visit I would like have her do the 30 second test and see how she compares to others of her age. Due to her stated tiredness I chose not to do the 30 second chair rise, but will do next visit or soon after as her tolerance improves.

3. Two Minute Step Test: She had to stop at 29 seconds with 27 steps, which is well below the norm for her age and is an indication of poor endurance.

4. Floor Rise Test: very impressive. She got up from the floor in 7 seconds and down in 5. She was one second faster than her peers in their 70’s. There are no norms for this test for 90 year olds.



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5. Oswestry Disability Index-‐ She scored a 48 which indicates moderate disability.

The remaining tests were of her impairments. They are listed below.

Strength: I did a detailed dynamometer test on her upper and lower extremities and she has some mild weakness in her quadriceps and left elbow flexors. All other major muscle groups are close to or above the norm. Her Core or abdominals are very strong for any age. She scored a 6/10 whereas most people score 3/10. Another impressive finding.

Posture Assessment was done on the Reedco and showed severe deficits in the head and upper back. She has a severe forward head and thoracic kyphosis (0/10).

Range of Motion is excellent except for dorsiflexion bilaterally. She should have 8 degrees and she has 0 degrees.

Conclusion: Her goals are to return to her prior activity level with her usual vim and vigor as well as to have no pain in her back or further fractures. Her major problems are endurance and posture. I gave her 5 exercises to work on these and I will see her again in two weeks to progress the program. It is attached.

Please feel free to contact me if you have any questions.

Sincerely,

Carole B. Lewis, PT, DPT, GCS, GTC, MPA, MSG, PhD, FAPTA



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Mid-‐level Case – Additional Test Information

2 minute Step Test Rikli RE, Jones CJ (1999). Functional fitness normative scores for community residing older adults ages 60-‐94. Journal of Aging and Physical Activity, 7, 160-‐179. 1. Take resting vital signs 2. Have patient/client stand next to a wall. Measure the height of the iliac crest and patella and mark

it on the wall. Then place a piece of tape on the wall half the distance between the two. 3. On the signal “go” the patient/client begins stepping (not running) in place, raising each knee to the

mark on the wall, for as many times as possible in the 2 minute period. 4. Only count the number of times the right knee reaches the required height. That is the score. 5. If the proper knee height cannot be maintained, ask the participant to slow down, or to stop until

they can regain the proper form, but keep the stopwatch running. 6. At the end of the test, provide a cool down by asking the patient/client to walk slowly for a minute. 7. A person with impaired balance may use the back of a chair as a touch-‐hold for stability. Note this

modification in your documentation 8. One trial. 9. Take post exercise vital signs.

Range of scores between the 25% and 75% percentiles

Age Number of steps – Women

Number of steps – Men

60 -‐ 64 75-‐107 87-‐115

65 -‐ 79 73-‐107 86-‐116

70 -‐ 74 68-‐101 80-‐110

75 -‐ 79 68-‐100 73-‐109

80 -‐ 84 60-‐90 71-‐103

85 -‐ 90 55-‐85 59-‐91

90 -‐ 95 44-‐72 52-‐86

Scores less than 65 were associated with lower levels of functional ability Population:

• community residing older adults ages 60-‐94

• n = 7,183 (5,048 women & 2,135 men) • years education: 14.5 • chronic conditions: 1.7 • medications: 1.6

• performed moderate exercise >3 times/week: 65%

Exclusion criteria: • advised not to exercise by physician • CHF, joint pain, chest pain, dizziness,

angina during exercise • BP > 160/100



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LOW LEVEL SCENARIO (Medical Overview June 2013) All identifying information has been removed. Information supplied by patient’s daughter.

AVOID NARCOTICS AND OPIATES IF POSSIBLE (SEE General Info/Cautions)

CURRENT – Nothing major since March 29, 2013 – under 24/7 home care since 3/29/13…bed ridden but almost daily, transferred to wheelchair for several hours. Last saw PCP 11/20/12…in-‐home check by Dr. R, MD 2/7/13. March 5, 2013 complaint of visual hallucinations but once I assured her that she was not nuts, they subsided. Right shoulder cannot lift due to pain and left one also hurts but can use…treated with heated shoulder pad and Voltaren Gel as needed—won’t take Tylenol.

RECENT HEALTH ISSUES

March 29, 2013 to present – AT HOME with 24/7 care by C and daughter. Temporary help and PT/OT stopped in April 2013.

March 18-‐29, 2013 (C. diff) – To hospital from home – with return of C. diff and UTI. Low potassium and magnesium…3/24 EKG “off” but not A-‐fib. Cardiac enzymes good/Holter heart monitor. Severe onset of gout. RELEASED TO HOME MARCH 29, 2013.

March 8-‐14, 2013 (bilateral pneumonia) – To hospital from SNF (was scheduled to be released from SNF March 8, but too sick) -‐ with bilateral pneumonia and UTI. Two C. diff cultures negative. Brought home for 1st time in 3 months on Mar 14. March 16 started massive black, smelly diarrhea (7x a day+), fever of about 100.5, doesn’t want to eat or take meds.

Jan 3-‐13, 2013 (C. diff and reaction to pain meds) – To hospital after daughter took from SNF for post surgery check at MFA (PCP recommendation to take to ER rather than back to SNF) – with major reaction to Fentanyl pain patch when combined with Tramadol and C. diff positive. Admitting symptoms: hallucinations, confusion, lack of eating & drinking, vomiting, diarrhea, swollen stomach, immense drowsiness, depression, lack of reaction or situational awareness, edema, etc

Dec 14-‐20, 2011 (broken femur/surgery) – To hospital from 4AM fall at home preceded by severe gout in right foot – surgery 12/15 for acute reverse comminuted intertrochanteric fracture right femur. Had two blood transfusions, one during surgery and a 2-‐liter transfusion 12/18. Released to SNF for rehab – SNF removed surgical staples 12/27. Follow-‐up appointments with Dr. A (surgeon) Jan 3, 2012 and with Dr. L Feb 3, 2012. Leg healing well.

BRIEF MEDICAL OVERVIEW: Heart attack (2000), 6 stents over the years…in 2007 minor strokes (not TIAs) & left/right CVAs (2007). Otherwise, possible unstable angina and/or possible GERD – pain only at night when lying down, systolic dysfunction, CAD, Hyperlipidemia (high chol -‐ controlled), Hypertension (controlled), Chronic Renal Insufficiency (first diagnosed 9/06). 4/28/10 Dr. W advises “moderate kidney insufficiency,” major balance issues (and falls – latest 12/14/11), urinary & bowel incontinence (wears diaper), Severe Obstructive Sleep Apnea (long-‐standing but first officially diagnosed at hospital Sleep Clinic in 2008—CPAP tried), and Osteoarthritis. Manual Extracapsular cataract surgery 8/11/09 (left eye). UGI/EDG, Polypectomy (Oct-‐Nov 2010 – hospital). Acute reverse comminuted intertrochanteric



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fracture right femur 12/14/11. Bilateral pneumonia 3/8/13. C. difficile (first was 1/3/13 and return 3/18/13). Subject to severe onsets of gout since 2007.

GENERAL INFORMATION & CAUTIONS!!!!!!

DOB: 01/01/18 … 5’3”…last known weight 163 on 2/29/12 @ SNF

SSN: xxx-‐xx-‐xxxx

VACCINES: (LAST flu shot 9/14/12 (CVS-‐HD)…pneumonia shot 10/28/09)

ALLERGIES/major sensitivities: NO NARCOTICS/opiates if possible. Has major reactions to opiates/narcotic meds. Fentanyl Patch (12/27/11-‐1/3/12) but was given when also on Tramadol for pain (major reaction – diarrhea, extreme confusion & drowsiness, hallucinations, lack of interest in eating or drinking, depression, etc). Morphine (itches and rash) and Demerol (hallucination). Anesthesia – tends to react strongly and can become very depressive. Medications: Prior stoppage of some meds on occasion (Plavix & aspirin) for surgery caused major internal itching (no rash). Increased Ranexa stopped due to dizziness, tremors and constipation.

NO FOOD ALLERGIES

GOUT: Subject to severe onset of “drug-‐induced” gout – treat immediately with Colchicine until gout pain stops. Has had 13 gout attacks in total starting in 2007 (last 3/24/12). Is on a preventive Allopurinal and, if needed for immediate attacks, Colchicine.

AVOID DYES: Has chronic renal insufficiency

C. DIFFICILE: Two onsets in lifetime both in 2013. Treated at hospital (Jan 3-‐13 and March 18-‐29, 2013) mostly with Vancomycin. Cause possibility due to antibiotics given for broken femur and later for bilateral pneumonia.

PROSTHETICS: (1) Knee replacements 1994 and 1997 (require potential antibiotics for major procedures?). (2) Partial upper bridge.

MEDICAL INSURANCE: Primary – Medicare, Parts A & B; Secondary – Tri-‐Care for Life

EMERGENCY CONTACTS: (1) Daughter has POA

LIVING WILL, ORGAN AND BODY PART DONOR, DURABLE POWER OF ATTORNEY: Yes On death, wishes to be cremated.

MOST RECENT LAB TESTS – (Most recent PCP physical 11/20/12)

2013 – Innumerable @ HOSPITAL in January and March (blood, cardiac enzymes (normal 3/26), EKGs, Halter monitor, CT scans of lungs, chest x-‐rays.



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2012 – Innumerable @ HOSPITAL in January and March (blood, cardiac enzymes (normal 3/26), EKGs, Holter monitor, CT scans of lungs, chest x-‐rays, echocardiogram (Jan 4)…Jan 3 and Feb 3 many x-‐rays on right leg fracture ,EKG/blood by PCP 5/15/12 and 11/20/12.

2011 – Innumerable @ HOSPITAL Dec 14 until release Dec 20, including CT brain scan, EKGs, blood, pelvic and right leg x-‐rays, etc. ). 2011 OTHER TESTS @ PCP office and Dr. B-‐ Echocardiogram (Dr. B 4/25/11 – perfect.

2010 & 2009: Oct/Nov 2010 UGI, EDG, Polypectomy @HOSPITAL. At HOSPITAL 9/29/10-‐Oct 5/10, had a heart echo, EKG, blood tests, chest x-‐ray, CT scan of brain, ultra-‐sound of liver/pancreas/gall bladder. At Thomas House 10/5/10-‐12/1/10: X-‐rays, C.difficile (NEG), ova/parasites (NEG). CVA DOPPLER – 4/1/09-‐W: very mild plaque rebuilding on left carotid.)

OTHER MEDICAL CONDITIONS

1. Chronic Renal Insufficiency – first diagnosed 9/06 during angioplasty, but fasting blood tests since have been up and down. For instance, blood tests during CEA surgeries (2007) showed kidney function okay. 4/1/09 non-‐fasting blood test shows kidney problem back. 5/4/09 fasting test okay. 10/14/10 fasting blood test showed slight increase. 3/28/11 fasting blood test showed kidney function stable, etc. Too many dyes in angio procedures? (NOTE: fasting normal is 70-‐100 mg/dL…100-‐125 considered prediabetes. If 126 on 2 tests, diabetes).

2. Two knee replacements – Jan 13, 1994 and Jan. 14, 1997 (may require antibiotics for invasive surgery or potentially infectious procedures)

3. Incontinence – neither Detropan nor Detrol work – wears diaper. Problem is with “feeling” and inability to walk.

4. Skin Cancers -‐7/5/05 (nostril basil cell carcinoma removed, Dr. M. On 8/25/09, PA froze off 2 precancer (face and chest). Full Body Check 11/23/09 (5 frozen off, one clipped – nothing a problem).

5. Sleep Apnea -‐ long suspected by daughter, confirmed while in HOSPITAL ICU 3/23-‐25/07. HOSPITAL Sleep tests confirmed (11/08). CPAP terminated 1/14/09 after week as patient could not adjust.

6. Irregular pap smear – 6/30/05 – second pap smear 10/25/05, normal

7. Eyes – Cataract surgery (left eye -‐ manual extracapsular) on 8/11/09 – 2/2011 lense correction left eye (Dr. Z). Years of Ptosis. PRIOR EYE EXAM 5/07: moderate cataracts, vision 20/40-‐20/50 uncorrectable but can use 3.5 reading glasses.

8. Teeth -‐Wears a partial upper bridge. Regular dentist Dr. G. Last Tooth extraction – 9/05/07 by Dr. C



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9. Gout (13 lifetime attacks) -‐ subject to “hospital/drug induced gout”. Had 2 severe bouts in 2/07 @HOSPITAL-‐-‐third was at home 4/14/07, 4th at home 7/28/09, 5th after transfer from HOSPITAL to Residences @ SNF– onset Oct 6, 2010. 6th onset 2/7/11, 7th onset at home in Feb 2011 (Uric Acid 7.2 mg/dl on 3/28/11), 8th 4/17/11, 9th 5/31/11, 10th 9/10/11, 11th 12/12/11,12th 3/19/12, 13th 3/24/12. Started Allopurinal 100mg 10/12/11 due to high uric acid (Dr. Wheaton.

10. Misc. -‐ Non-‐rheumatoid arthritis, torn fascia, Morton’s Neuroma

PERTINENT HOSPITALIZATIONS/ER VISITS

1/13/94 & 1/14/97 – knee replacements in both legs (Arkansas)

3/9/00 – 2 stents at X HOSPITAL (80% blockage on right/90% on left)

2/13/03 – fall resulted in 12 stitches at HOSPITAL ER

6/20/03 – stent on RCA (HOSPITAL –(100% blockage)

7/23/04 – cardiac cath (HOSPITAL) – no stent

9/29/05 – stent on RCA (X Hospital Center – Seides) – 70-‐80% blockage. Some blockage in LCA, but no stent or by-‐pass recommended.

9/14/06 – 2 stents (RCA) – X Hospital Center LCA unchanged.

9/18/06 – Back to X Hospital Center for pseudo aneurysm (thrombin injection)

2/17/07 – ER, minor strokes (not TIA). Carotid stent unsuccessfully attempted 2/23.

11/01/07 – HOSPITAL ER (911) – Severe chest pains. Diagnosed as “Acid Reflux”

11/06/08 & 12.04/08 – HOSPITAL Sleep Clinic diagnoses severe obstructive sleep apnea. 11.06.08, flunked HOSPITAL Sleep Clinic apnea test “overnight split polysomnogram”. Only slept 2 hours (stopped breathing 90? times). Follow-‐on CPAP poly titration done 12/04/08. CPAP Mask provided 1/12/09 (refit 2/3/09). Terminated CPAP 2/09 (patient could not adjust).

12/19/08 – HOSPITAL ER (911) – Severe chest pains. Sonogram in ER/ Diagnosed as GERD. Admitted to HOSPITAL. Released 12/21.Revised meds effective 1/13/09 to include angina and GERD. Chest pains resumed 3/09 some mild/some severe.

8/11/09 – Cataract surgery (left eye) – Dr. Z – 2/2011 lense correction

9/29/10 to 10/5/10– HOSPITAL ER (911) – Admitted 9/29/10 thru ER to medical ward. Many tests (see “Lab Tests below). Released 10/5/10-‐12/1/10 to a skilled nursing facility) for rehab with undiagnosed causes.



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Upper GI done 10/19/10 and EDG/Polypectomy 11/2/10. Nausea returned with some vomiting 12/10/10. Prior Symptoms: week of nausea, weakness, headaches -‐ occasional depressive states, not eating well and not drinking well, but occasionally better. On 9/28, almost back to normal. Early AM of 9/29, total reversal -‐ could not move out of bed, sit up, white as a sheet, not mentally or speaking well. Called 911.

12/14/11 to 12/20/11 – HOSPITAL ER (911). Surgery for acute reverse comminuted intertrochanteric fracture (right femur) Dec 15. Discharged to SNF.

1/3/12-‐1/13/12 – back at HOSPITAL thru ER for reaction to narcotic meds and C. diff.

3/8 -‐14/13 – back at HOSPITAL with bilateral pneumonia and urinary track infection. Testing for possible return of C. diff. was negative. Discharged to SNF.

3/18/13 – back to HOSPITAL with C. diff and UTI. Discharged home 3/29/13.

MORE MEDICAL DETAIL/HISTORY

2011 – Sudden Onset of Edema (first ever) on Friday March 3/25/11 – face and feet (worse on left foot –also spread to lower left leg). Artificial knees ached and puffy. Worse at night. No direct cause (reduced salt). Fasting blood test revealed no cause. Edema resolved itself in about a week. Echocardiogram on 4/25/11 (Dr. B) – “heart of a 70 yr old”.

2010 – Had UGI at HOSPITAL 10/19/10 and EDG/Polypectomy 11/02/10….PRIOR 9/29/10-‐10/5/10 at HOSPITAL admitted thru ER after sudden onset of nausea to food (but not vomiting), headaches, can’t eat (all new symptoms for her). Comes and goes – many tests done but no GI stuff, except for an ER ultrasound that ruled out gall stones or pancreatitis – discharged from HOSPITAL 10/5 with undiagnosed sudden onset of nausea to food (not vomiting) to R (SNF). SNF stool sample revealed no parasites, cysts, ova or C. difficile. PCP ordered Upper GI 10/19/10, which revealed mass. Upper Endoscopy (EGD) and snare polypectomy (3cm polyp that had prolapsed into duodenum) done 11/02/10. Released from SNF Dec 1 to home with some assistance. Started vomiting afternoon food every other day or so starting around Dec 10. 12/13/10 taken to primary care physician and gastroenterologist. PCP added Zoloft and later Mirtazapine. Gast doc believes new nausea might be due to constipation. Recommends barium enema but try ClearLax first, worked.

FALLS (balance issue) – 2011: 4/5 & 6/11 tripped in bedroom (not hurt). 12/14/11 broke her femur. Worsened after CEA surgeries in Feb & Apr 2007. Prior in-‐home falls 5/24/10 (fell on back in bedroom and hit head)… 10/26/09 and 8/09 – slipped off bed (FD called to get her up & fell again 8/28 (doorman); two 3/09 (bed and chair). Others: 10/18/07 and 10/19/07 (4AM) – Numerous bruises. (Last outdoor fall in 9/07. Prior outdoor fall 2/13/03 (12 stitches at HOSPITAL ER.) PT/OT has not helped. Stopped 8/29/07). Uses wheelchair outside apt. Inner ears last checked 6/14/07 (not a problem), but hearing and eyesight not good.



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ANGINA and/or GERD (ongoing) – ANGINA/GERD – latest 9/9/11 (mild to severe chest pain radiating down arms to elbows about an hour after tries to go to sleep, even after not eating for 14-‐14 hours – currently 4-‐5 x/month), but can be more frequent. Only relieved if sits up – Meds changed 1/13/09 at HOSPITAL, BUT night time chest pains resumed (3/6/09) and continue but less pain and less frequently. 4/1/09 saw Dr. W -‐ doubled nighttime Ranexa 4/1 to 1000mg – stopped 4/6/09-‐ bad reaction (dizziness, tremors, constipation) but chest pains stopped for awhile. AS OF 5/3/10, CHANGED Omerprazole to Pantoprozole. History: Last admitted to HOSPITAL (thru ER) Friday, 12/19/08 (released 12/21). New medications started 1/13/09 – seemed to be working (BUT then chest pain started-‐up again in March 09). Pains occur even after 12 -‐14 hours of NOT eating. GERD vs. Angina?

LAST ER 12/19/08 for chest pains -‐ revised medications started 1/13/09—worked for awhile. Pains resumed in March 2009. PRIOR ER: 11.01.07. 9/20/07 (3PM) on walk, broke out into a sweat, weak all over (arms and legs) and had to be driven home after short walk. Took her 10/9/07 to see Dr. S (blood pressure and EKG okay) – Dr. B said “not cardiac” and to see Internal Med doctor W. 10/12/07 – short walk to park bench, overall weakness, hard to breathe, no sweat – wheelchair home. 10/28/07 started getting significant chest pain (every night) when lying down on head “elevated” sleep. 11/01/07 (1AM) immediately got chest pain on lying down to go to sleep – worse than last few days and in arms. Used a slightly “overdue” Nitro-‐patch and gave some relief. Same day (4AM) very severe chest pains, radiating down arms and weakness. Called 9-‐11 – to Hospital ER around 4:30AM, eventually admitted to Cardiology ward and discharged afternoon of Friday, 11/02/07. (Diagnosis by Drs. B was “Acid Reflux” and beyond EKG and blood tests, further cardiac testing cancelled by Dr. B) Sent home with 4 new “meds” – Mylanta, Pepcid AC, Isosorbide Mononitrate, and as needed, NitroQuick (0.4mg, sublingual). (Note: during hospital stay at around 1AM 11/02, got an “attack” – b/p pressure spiked and nitro pill given twice and brought some relief.) On 12/19/08 back in hospital ER for severe chest pains.

OLDER INFORMATION: Since release from HOSPITAL on afternoon of 11/02/07 (diagnosis “Acid Reflux”): Subsequent “Attacks” – one at 4AM 11/03 (tried one more Pepcid AC and a swig of Mylanta – no relief until she got up at 7AM – no sleep)…another at 9:30PM, 11/03 (after very lite dinner at 7PM and a brief walk in the hall at 9:30PM – became very breathless at end of walk, went back to sit up on bed, severe chest pains, gave 2 NitroQuick – 1st worked fast, 2nd got rid of pain)…11/04 (about 3.5 hours after prior attack, further “attacks” at hourly intervals 1AM, 2AM, 3AM – for 1AM took 2 NitroQuicks and worked, for 2AM 2 more NitroQuicks but worked less quickly, for 3AM, no pills – toughed out getting minor exhaustion sleep. One hour after meal (chest pains 4:30PM, 5:45PM, 7PM, 8:50PM . 11/05 (first at 7:30AM), 11/06 (first at 1:40AM) – “attacks” continue – fewer and pain less severe (nighttime) – on 11/06 happened again as soon as laid down to sleep (last two meals were chicken noodle soup only, nothing after 6PM). If sits up immediately, keeps pain and length under control. 2008 2/24/08 12:30PM right after lying down (chest tightness at night 2/25 and 2/26), 2/27 2AM sat up but angina pain (both arms too) lasted on & off for an hour – saw Dr. W 2/27 – ekg and b/p normal – (nothing on 2/28). On 2/29/08 again had late night chest pain radiating down both arms – took 1 subling. Nitro – did not work – took Ambien generic and slept, with 1-‐2 bathroom visits. 3/1 (took sleeping pill – no problems). 3/2 (did not take sleeping pill but had all night problems (took two nitro pills…one gave relief for 2 hours,



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the other for a few hours, finally fell asleep at 8AM). 3/3/-‐ took sleeping pill at midnight (last meal 4PM), immediate burning pain – no nitro, up all night. CHEST PAINS CONTINUED 3-‐4x A WEEK.

STROKE/CAROTID ARTERY SURGERY HISTORY (2007-‐HOSPITAL) – History

Stokes and carotid artery blockage confirmed by MRI 2/18/07. . MORE DETAIL: 2003 – Sonogram carotid test shows “potential significant blockages in right carotid, but Dr. B ordered follow-‐on HOSPITAL MRA (6/5/03) says carotids and arteries going to head remarkable for her age??? NO FURTHER TESTS DONE ON CAROTIDS BY DR. B. On Saturday 2/17/07, taken around 6:30PM to HOSPITAL ER with subtle symptoms of inability to find some words, anxiousness and tentativeness. Admitted to Acute Stroke Unit (Neurology). MRI on 2/18 confirmed several tiny strokes and carotid artery blockage (99% on left…80% on right). Echocardiogram and Doppler further characterize. Stent attempted Fri, 2/23 by Dr. V – unable to do due to fresh clot at site. CEA done 2/24 (Dr. V.). Released 3/1. Two acute attacks of drug-‐induced gout. Depressive reaction to anesthesia on 2/24-‐25 (convinced was dying). SLEEP APNEA confirmed while in ICU.

4/10/07 – 2nd CEA – Left carotid artery surgery (80% blocked) and was very friable. Released from HOSPITAL 4/13/07. Pre-‐op issues – Aspirin and Plavix stopped 4/4 – caused major internal itching (no rash). Post-‐op issues – major problems with throat and phlegm (breathing tube) and edema in arms and both ankles and feet (worse in right). Once home, throat problems, left index finger tingled or was numb for weeks (nerve?), onset of acute gout right foot 4/14 (one week prednisone pack stopped), breathlessness and tiredness, surgical site pulls, sore, urinary incontinence worse.

6/5/07 – Major balance problems, feeling worse, breathlessness, finger numb, fluctuating blood pressure, mentally “down” (6/4/07 saw cardiologist Dr. B, who recommended seeing neurologist and an anti-‐depressant. Internal Medicine doctor did not think patient needed anti-‐depressant so never taken.

10/07 – fell twice in home.

CARDIAC HISTORY – History

1. HEART ATTACK (3/5/2000) – angiogram 3/8/00 – angioplasty 3/9/00 – two stents (left groin) – 80% blockage on right, 90% blockage on left

2. SEVERE ANGINA EVENT (6/18/03) – on 6/20/03 Cordis CYPHER stent implanted at HOSPITAL in right artery (100% blockage)

3. ANGINA (7/23/04) – cardiac cath at HOSPITAL – no stent

4. SEVERE Angina event (9/10/05) – on 9/29/05 Taxus Express 2 Paclitaxel-‐Eluding Stent (3.5x33mm) inserted in RCA (70-‐80% blockage) by Dr. S at HOSPITAL by PCI (rescheduled from 9/21). Also found some blockage in left feeder into left LCA but does not recommend stent or by-‐pass. Does not believe this left blockage was causing symptoms. Discharged 9/30/05. (Post-‐procedure: still easily fatigued, very wobbly walk, vision problems and left eyelid suddenly



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drooped more significantly – ophthalmologist says prob. Due to anesthesia and break off of plaque).

5. SEVERE ANGINA EVENT (8/23/06) – Cardiac cath (right groin) on 9/14/06 with Dr. S. Two Cordis Cypher stents inserted in Prox-‐RCA (3.5x13mm to address blockage in 3/00 stent…and 3.5x33mm Cordis Cypher to address partial restenosis in mid RCA in 9/29/05 Taxus stent). Did ultrasound to check stents. RCA looks good. Still has unchanged blockage into LCA, but current symptoms attributed to RCA blockage. If restenosis occurs again, may recommend “intracoronary radiation therapy with balloon angioplasty” rather than more stents, although stents still possible. (Post-‐procedure: Medications slightly changed. On Sunday, 9/17, was awakened at 1:30AM at home with pain and stinging sensation in groin. Large (fist sized) hematoma – hard and feverish. Contacted Dr. M (on call) and hours of pressure on site relieved pain. Dr. B checked site on 9/18. Ordered ultrasound on 9/18—pseudo aneurysm). Returned to HOSPITAL 9/18 – Thrombin-‐injection. Released 9/20/06. ISSUE: Diagnosed with Chronic Renal Insufficiency.

LOW LEVEL SCENARIO (Current Medication Updated June 2013)

This Information received from patient’s daughter – All identifying information has been removed

Last PCP Blood Work 11/20/12 AVOID ANY USE OF NACAROTICS/OPIATES IF POSSIBLE – major reaction IF NEEDED – Colchicine 0.6 mg for severe onset of acute gout. Immediately give 1 tab by moth twice daily until pain is gone (10/22/07) A. BREAKFAST (6 pills) – Miralax in juice

1. ATENOLOL (Tenormim) – 25 mg (B Blocker). Dr. W 90 days a) paid $15 for 90 (4/2/13) b) paid $15 for 90 (1/4/13) c) paid $9 for 90 (12/14/10)

2. AMLODIPINE – 5 mg (high blood pressure). Dr. W 90 dys, but CVS giving 30 day prescription for $5 on 6/13/13 a) HOSPITAL added 3/14/12 in lieu of Lisinopril 2.5mg. Changed at HOSPITAL to 5 mg on

March 29 release from hospital. b) 5 mg added at HOSPITAL 1/5/12 when b/p spiking c) Reduced to 2.5 mg 2/28 at SNF as b/p was 125/51.

3. ASPIRIN – 81 mg (anti-‐platelet). OTC 4. LASIX (furosemide) 20 mg (diuretic)

a. Was increased at SNF to 40 mg in Jan or Feb 2012 b. Then reduced back to 20 mg 2/28/12 as b/p was 125/51 c. Dr. W 90 days (paid $8.35/90 in 10/06/11 d. Paid $7.85 for 90 11/19/12 e. Paid $7.85 2/15/13



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5. Ranexa extended release 500 mg (agina) started 1/13/09 a. Dr. W 90 dayd $36 10/19/12 but written for 2 x day

6. Vitamin D3 2000 units/day OTC – added at SNF in Jan 2012 a. Per 11/20/12 blood test @ Dr. W office, keep taking

B. LUNCH (4 pills with 5th pill of potassium occasionally) 1. Plavix (clopidogrel) 75 mg (anti-‐platelet)

a. Dr. W 90 day ($15) for 90 (5/25/13) b. Started generic in July 2012 (before paid $36/90 days on 3/1/12)

2. Lansoprazole DR 30 mg tablet started 11/25/12 (4/7/13 paid $17.65; 3/06/13 paid $11.54 for 30 days)

a. Prior Omerprazole (Prilosec) 40 mg started 1/13/09 b. Stopped 5/3/10 due to studies that it interferes with Plavix c. Then took Pantoprazole until price raised to $75 (GERD?)

3. Zoloft 25 mg (taking sertraline) – antidepressant a. Started @ 25 mg 12/15/10 – increased in Feb 9, 2012 to 50 mg at SNF b. Reduced back to 25 mg at HOSPITAL on 3/14/12 c. Dr. W 90 day ($3.21 on 11/19/12) d. Paid $5 for same 3/1/12 e. Paid $8.80 on 6/3/13 for 90 days

4. Occasionally – Potassium 10 Meg (KLOR-‐CON) a. Added first at HOSPITAL 3/29/12 b. Potassium Chloride extended release (KLOR-‐CON: 20 Meg by mouth once daily for a

month or until diarrhea stops (Per Dr. W 5/15/12 keep taking but daughter advised her she was going to cut the dosage by half

c. Daughter cut to 19 Meg 5/15/12 as blood tests showed potassium levels high and only gives occasionally – $5 for 30 on 6/25/12… then just gave occasionally as eats lots of fruit.

C. DINNER (3 pills plus 2nd dose of Miralax and occasionally packet of Floranex Oral Granules (lactobacillus – $84.04 on 1/10/13 1. Zocor (taking generic simvastatin) 20 mg (lipid lowering)

a. Take at night (Dr. W 90 days – $15 on 11/19/12) b. $15 for 90 on 5/25/13

2. Zetia (cholesterol) 10 mg a. Dr. W 90 days $51/90 on 4/7/13 b. $36 on 1/10/13 c. Paid $27 on 12/14/11

3. Mirtazapine 7.5 mg (common name Remeron) – antidepressant/increase appetite a. Started 1/14/11 @ 7.5 mg b. Increased to 15 mg 2/23/11 c. Decreased to 7.5 mg on 10/24/11 d. SNF added to AM regime Jan 2012 – Dr. W 90 day cost 4/12/13 – $15



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Arthritic Shoulders

• Have neck wrap, heat in microwave 4 minutes • Effective 2/8/13 per Dr. R • Trying Voltaren 1% Gel 3 x a day ($17) • If really bad, 1 or 2 x strength Tylenol

Bowels – If get constipated, use Clearlax original prescription strength (Polyethylene Glycol 3350) or Miralax 2 x everyday

• Colace stool softener or Ducolax Laxative or suppository or other as needed

Low-‐level Case – Letter to Physician

Dear Dr. W,

I had the pleasure of working with Mrs. B today. (7/6/2013) She is a charming and delightful lady. Besides the detailed history that her daughter sent to me, Mrs. B revealed additional information. After her last hospitalization in (3/2013) she has not walked. She said she was in the hospital before this and did walk after leaving the hospital. Her daughter and care giver C provide most of her care. However, now Mrs. B would like to explore the possibility of walking. She has refused any rehabilitation since her hospitalization up until now.

Her current daily mobility regime is to do a maximal assist sliding transfer to the wheelchair once a day. She then sits up in the wheelchair for 2 hours and transfers back. I asked her about pain and in the bed but she claims pain is not much of an issue. However, when we moved her shoulder around and she attempted to stand, she did say she had some pain (0-‐8 but only with movement and standing and variable).

On an objective mobility exam she showed the following:

• 95% Oxygen saturation in supine, which declined to 89% in sitting.

• Her heart rate was 65 in supine and dropped to 60 after 5 minutes of sitting and after standing attempts.

• When she returned to bed at the end of treatment her heart rate was 65 and Oxygen saturation was 97%.

• Her range of motion in the hand and elbow are normal but both shoulders are limited and she has noted weakness in both upper extremities. These values are noted below:

o Shoulder Flexion – left 91 degrees, right 7

o Shoulder Abduction-‐ left-‐ 87 degrees, right 3

o Shoulder internal rotation-‐ left 61 degrees, right 0

o Shoulder external rotation-‐ left-‐ 23 degrees, right 0



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• Strength was not tested in the shoulders at this time due to the limited Range of motion and pain.

The following muscle tests were done and you can see that she has significant weakness in both upper and particularly the lower extremities (# = pounds)

o Elbow Flexion: left 13#, right 15# (Norm = 29#)

o Elbow Extension: left 9 #, right 12# (Norm = 20 #)

o Knee extension: left 9#, right 4# (Norm = 50#)

o Hip Flexion: left 22#, right 7# (Norm = 31#)

o Hip Abduction: left 7#, right 6# (Norm = 38#)

Her most notable active motion deficit is in both ankles. In supine, she has motion only -‐30 to minus 40; however, in sitting she could get to neutral.

We also attempted a stand from the wheelchair and she was able to come to a partial stand 3 times with maximum assist of two.

Her score on the Function in Sitting Test (FIST) is 12/56 which shows some ability in sitting but also demonstrates her potential to improve in this area. Her Patient Specific Functional Scale (PSFS) is shown below and identifies the areas where she would like to improve in her abilities to function more independently ( walking, standing, dressing , toileting and sitting).

Finally, I watched C (her caregiver) work on bowel activities in bed and found that Mrs. B did contribute to this activity, but it is still a maximal assist on the caregiver’s part.

We agreed to try an exercise and standing program aimed at increasing the much-‐needed strength. Attached is the exercise program that we will start with.

I do think she has great potential and can improve the very weak muscles that she has and become more independent in her daily activities. The good news is that the muscles are all working; they are just very weak. I have sent her daughter the same copy of the exercises that I am sending to you and Mrs. B. C and they all seem to understand how to do them and seem committed to doing them.

Please let me know if you have any questions. Thank you so much for referring Mrs. B to me. After the long wait to see her, it truly was a pleasure.

Sincerely,

Carole B. Lewis, PT, DPT, GCS, GTC, MPA, MSG, PhD, FAPTA



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Functional Test Score Sheet NAME: __________________________ Date________

Tests Actual Norms

6 MWT __________ ft/meters MCD = 20 (Steffen 2002)

Age Meter FT 60-‐69 M = 572

F = 538 M = 1876 F = 1765

70-‐79 M = 527 F = 471

M = 1729 F = 1545

80-‐89 M = 417 F = 392

M = 1368 F = 1286

2 minute Step Test ___________ # of Steps

Age Men Women 60-‐64 106 97 65-‐69 101 93 70-‐74 95 89 75-‐79 88 84 80-‐84 80 78 85-‐89 71 70 90-‐94 60 60

Gait Speed 4M = 13.1ft 5M = 16.4ft 10M = 33.4ft

____________ft/meters

Age Comfortable Gait Speed

Fast Gait Speed

60-‐69 M = 1.59m/s F = 1.44m/s

M = 2.05m/s F = 1.87m/s

70-‐79 M = 1.38m/s F = 1.33m/s

M = 1.83m/s F = 1.71m/s

80-‐89 M = 1.21m/s F = 1.15m/s

M = 1.65m/s F = 1.59m/s

TUG ____________ seconds

Age # of sec 30-‐50 4-‐5 sec 60-‐69 5.6 sec 70-‐79 6.7 sec 80-‐89 7.8 sec

(Vereeck 2008)

30 sec Chair Rise ____________ times

(Rikli & Ins 2013)

Age Men Women 60-‐64 <17 <15 65-‐69 <16 <15 70-‐74 <15 <14 75-‐79 <14 <13 80-‐84 <13 <12 85-‐89 <11 <11 90-‐94 <9 <9

Stair Climb ____________seconds .5 sec / stair Record # and time (Bergland 2008)

Floor Rise Up/Down = ____ /____ seconds

8 sec up and 6 sec down (Bergland, 2005)

© Copyright 2016 Carole Lewis. All rights reserved.



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REFERENCES

mfr case study details b - amazon s3 · mastering*functional*reporting*case*scenarios*...

Documents

mfr case study details b - amazon s3 · masteringfunctionalreportingcasescenarios*...