Sub-acute cases. 2024.docx

**Assessment Task 3: Practical Exam - Cases** **[CASE 1: Mr/Ms Johns -- Lumbar Spine Fusion]\ HPC: Mr/Ms Johns is a 70-year-old person admitted for L1-L3 Lumbar Spine Fusion. S/he fell off a curb and presented 1/52 after the fall with worsening mid back and left flank pain. CT scans showed a L1 and...

**Assessment Task 3: Practical Exam - Cases** **[CASE 1: Mr/Ms Johns -- Lumbar Spine Fusion]\ HPC: Mr/Ms Johns is a 70-year-old person admitted for L1-L3 Lumbar Spine Fusion. S/he fell off a curb and presented 1/52 after the fall with worsening mid back and left flank pain. CT scans showed a L1 and L2 compression fracture with a retropulsed fragment causing a 20% canal compromise. Other chronic degenerative changes were noted. Underwent above surgery and is in private inpatient rehabilitation 1/7 post-surgery.** **PMHx: HTN** **SHx: Lives alone in double story home, previously indep nil aid. 3 x stairs FA nil rail, 5 x internal stairs nil rail. Retired, however engages in frequent community ambulation, volunteers at local community garden and enjoys bushwalking.** **Precautions: Standard precautions for LSF lasting for 6/52.** **Current obs: HR: 60, SaO2: 99% 2L 02 via NP, RR: 18, BP: 124/80 (lying), temperature 37.4, ECG: Normal Sinus Rhythm, Ausc: NAD, pain at rest: 2/10. Panadol 500mg and Endone 5mg taken 45 mins ago with good effect.** **Mr/Ms Johns is 1/7 post surgery. S/he shows some fear of movement. Below is a summary of his/her current impairments/activity limitations tested, to date.** +-----------+-----------+-----------+-----------+-----------+-----------+ | **OBJECTI | | | | | | | VE | | | | | | | -- | | | | | | | Musculosk | | | | | | | eletal | | | | | | | Assessmen | | | | | | | t | | | | | | | (Impairme | | | | | | | nts)** | | | | | | +===========+===========+===========+===========+===========+===========+ | | **Right** | **Left** | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Pain** | Fusion | | | | | | | site 2/10 | | | | | | | (resting) | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Joint | Hip flex | Hip flex | | | | | range** | 45 P1 | 45 P1 | | | | | | | | | | | | **AROM | Hip abd | Hip abd | | | | | (deg°)** | 25 P1 | 25 P1 | | | | | | | | | | | | | Knee | Knee | | | | | | flex/ext | flex/ext | | | | | | WNL | WNL | | | | | | | | | | | | | Ankle | Ankle | | | | | | DF/PF WNL | DF/PF WNL | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Muscle | **Right** | **Left** | **Muscle | **Right** | **Left** | | strength* | | | strength* | | | | * | | | * | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 3- | 3- | | flex** | | | flex** | (limited | (limited | | | | | | by pain) | by pain) | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 3- | 3- | | abd** | | | ext** | (limited | (limited | | | | | | by pain) | by pain) | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Hip | 3- | 3- | | flex** | | | Abd** | (limited | (limited | | | | | | by pain) | by pain) | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Hip | 3- | 3- | | ext** | | | ER** | (limited | (limited | | | | | | by pain) | by pain) | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Knee | 4 | 5 | | flex** | | | flex** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Knee | 4 | 5 | | ext** | | | ext** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | **Ankle | 5 | 5 | | flex** | | | DF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | **Ankle | 5 | 5 | | ext** | | | PF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ +-----------------------+-----------------------+-----------------------+ | **OBJECTIVE - | | | | Musculoskeletal | | | | Assessment (Activity | | | | Limitations)** | | | +=======================+=======================+=======================+ | | **No. and amount of | **Kinematic | | | assist** | assessment** | +-----------------------+-----------------------+-----------------------+ | Bed mobility | X 1 mod A | \- Difficulty | | | | remembering steps of | | | | log roll and SOEOB. | | | | Requires A to SOEOB. | | | | | | | | \- Pain 4/10 when | | | | performing bed | | | | mobility | +-----------------------+-----------------------+-----------------------+ | Sitting (static) | (I) | 100% thigh support | +-----------------------+-----------------------+-----------------------+ | Sit to Stand | X 1 SB A nil aid | Final hip alignment | | | | slightly flexed | +-----------------------+-----------------------+-----------------------+ | Standing (static) | X 1 SB A nil aid | Hip alignment flexed | +-----------------------+-----------------------+-----------------------+ | Transfer (to chair) | X 1 min A w/ FASF due | Reduced hip and trunk | | | to pain | extension pain 5/10 | +-----------------------+-----------------------+-----------------------+ | Walking | X 1 min A w/ FASF due | Reduced hip and trunk | | | to pain | extension pain 5/10 | +-----------------------+-----------------------+-----------------------+ **[CASE 2: Mr/Ms Cullen -- Total Hip Replacement]** **\ HPC: Mr/Ms Cullen is 60 years-old, in private inpatient rehabilitation 1/7 after (R) THR for an intracapsular neck of femur fracture after being hit by a bicycle. The surgery was performed under general anaesthesia with a posterior approach, without complication.** **PMHx: Hypothyroidism; Ex-smoker quit 15 years ago, pack-year Hx = 14.** **SHx: Mr/Ms Cullen lives alone in a split-level house. FA: 1 step nil rail. Internal: 1 steps x 1 rail. RA: 4 steps x 2 rails. She was previously (I) mob nil aid, (I) ADLs and was driving. She does her own cooking, cleaning and shopping. She enjoys playing bingo on Wednesdays and walking with friends on Tuesdays and Saturdays. Her two adult sons live nearby. His/Her BMI is 18.** **Surgeons notes: Oral analgesia, WBAT, standard hip precautions (6/52), TED socks.** **Nursing notes (1 hour ago): HR: 69, SaO2: 99% NP, RR: 18, BP: 118/70 (lying), temperature 37.6, ECG: Normal Sinus Rhythm, Ausc: Decreased breath sounds bibasally, some coarse crackles B/L lower zones, pain at rest: 5/10. Panadol 500mg and Endone 10mg taken 1/24 ago with good effect.** +-----------+-----------+-----------+-----------+-----------+-----------+ | **OBJECTI | | | | | | | VE | | | | | | | -- | | | | | | | Musculosk | | | | | | | eletal | | | | | | | Assessmen | | | | | | | t | | | | | | | (Impairme | | | | | | | nts)** | | | | | | +===========+===========+===========+===========+===========+===========+ | | **Right** | **Left** | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Pain** | Hip 2/10 | NAD | | | | | | (resting) | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Joint | Hip flex | Hip flex | | | | | range** | 45 P1 | 130 R2 | | | | | | | | | | | | **PROM | Hip ext 0 | Hip ext | | | | | (deg°)** | P1 | 20 R2 | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Muscle | **Right** | **Left** | **Muscle | **Right** | **Left** | | strength* | | | strength* | | | | * | | | * | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 3 limited | 5 | | flex** | | | flex** | due to | | | | | | | pain | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 3 limited | 5 | | abd** | | | ext** | due to | | | | | | | pain | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Knee | 4 | 5 | | flex** | | | flex** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Knee | 4 | 5 | | ext** | | | ext** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Ankle | 5 | 5 | | flex** | | | DF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Ankle | 5 | 5 | | ext** | | | PF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | | | | | flex** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | | | | | ext** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ +-----------------------+-----------------------+-----------------------+ | **OBJECTIVE - | | | | Musculoskeletal | | | | Assessment (Activity | | | | Limitations)** | | | +=======================+=======================+=======================+ | | **No. and amount of | **Kinematic | | | assist** | assessment** | +-----------------------+-----------------------+-----------------------+ | Bed mobility | x 1 min A | Assistance to | | | | stabilise upper body | | | | while going from | | | | lying to SOEOB | +-----------------------+-----------------------+-----------------------+ | Sitting (static) | (I) | 100% thigh support | +-----------------------+-----------------------+-----------------------+ | Standing up | X 1 mod A | ↓ weightbearing | | | | through (R) LL | | | | | | | | ↓ (R) hip and knee | | | | ext in final | | | | alignment | +-----------------------+-----------------------+-----------------------+ | Standing (static) | X 1 mod A nil aid | ↓ (R) hip and knee | | | | ext in final | | | X 1 SB A W/ FASF | alignment | | | | | | | | ↓ weightbearing | | | | through (R) LL | | | | (approx. 50%) | +-----------------------+-----------------------+-----------------------+ | Transfer | X 1 mod A with FASF | ↓ (R) hip | | | | abd/stepping to (R) | | | | | | | | ↓ weightbearing | | | | through (R) LL and | | | | weight borne through | | | | hands when stepping | | | | to (L) | +-----------------------+-----------------------+-----------------------+ | Walking | X 1 mod A with FASF x | Shuffling gait | | | 10m (limited by | | | | fatigue and pain) | Stance: | | | | | | | | - ↓ (R) hip ext | | | | | | | | - ↓ (R) knee ext | | | | | | | | Swing | | | | | | | | - ↓ (R) hip flex | +-----------------------+-----------------------+-----------------------+ | Stairs | Not yet assessed | | +-----------------------+-----------------------+-----------------------+ **[CASE 3: Mr/Ms Stewart -- Rotator Cuff repair]** **\ HPC: Mr/Ms Stewart is a 54 y/o male/female post left open RTC repair. S/he sustained the injury during his/her weekly volleyball game, after FOOSH following a spike. S/he felt a searing pain and was unable to actively abduct his/her left arm, and sought medical advice. S/he was diagnosed with a massive full thickness rotator cuff tear (retraction of a supraspinatus to the glenoid rim) and surgical repair was advised.** **PMHx: HTN, bilateral knee OA, GORD, hernia repair in 1999** **\\** **SHx: Lives with partner, who is well, in double storey home. Mr/Ms Stewart is employed in the police force and was on active duty prior to the injury. S/he is on extended sick leave with pay presently, of which there is 4/12 left. S/he coaches his daughter's representative cricket team on weekends and enjoys bushwalks.** **Surgery: An open repair surgery was performed. A medium sized incision was made in the deltoid to access the rotator cuff. The supraspinatus had retracted and was pulled back. The supraspinatus was fixed to the humeral tuberosity using a transosseus suture. Biceps tenodesis was performed. No complications were reported from the surgery.** **Surgeons notes:** **0 - 2 Weeks** **Sling at all times** **Post-op r/v 2/52 outpatient rooms.** **2 - 6 Weeks** **Pendulum and PROM (flex/abd) shoulder** **Wrist and hand AROM. Scapula AROM.** **No active biceps.** **Sling at all times except when performing PT exercises.** **6 - 9 Weeks** **Stage I -- Active Assisted ROM** **Wean Sling** **9 - 12 Weeks** **Stage II -- Active ROM** **12 - 16 Weeks** **Stage III -- Light TheraBand strengthening.** **16 weeks -- 24 weeks** **Stage IV -- Progressive resistance training** **6 Months** **Unrestricted Activities (avoid heavy lifting/repetitive overhead work for 6 months)** **OBJECTIVE -- Musculoskeletal Assessment (Impairments)** ----------------------------------------------------------- ----------- ---------------- --------------------- ----------- ---------- **Right** **Left** **Pain** N/A 3/10 (resting) **Joint range PROM (deg°)** N/A Not tested **Muscle strength** **Right** **Left** **Muscle strength** **Right** **Left** **SH flex** 5 Not tested **Hip flex** 5 5 **SH abd** 5 Not tested **Hip ext** 5 5 **Elbow flex** 5 Not tested **Knee flex** 5 5 **Elbow ext** 5 Not tested **Knee ext** 5 5 **Wrist flex** 5 5 **Ankle DF** 5 5 **Wrist ext** 5 5 **Ankle PF** 5 5 **Fingers flex** 5 5 **Fingers ext** 5 5 **[\ ]** **[CASE 4 MR/MRS CAMPBELL ACL RECONSTRUCTION]** **HPC: Mr/ Ms Campbell is a 17 y/o male/female who is 1/7 post right ACL reconstruction. He/she sustained the injury when landing after attempting a mark in an AFL game 6 weeks ago. He/she was forced to leave the field of play. MRI scan revealed a complete rupture of the ACL ligament along with bone bruising on the tibial plateau and medial femoral condyle and a horizontal tear of the medial meniscus. After orthopaedic review, he/she opted for rehabilitation and early surgical reconstruction.** **PMhx: Appendectomy 2022** **Shx: Lives with his parents and younger brother in a two-story home. Internal 12 steps x 1 rail. He/she is in year 12 in school and has to get the bus to school. There is a 5-minute walk to the bus stop and 10-minute walk to the school. His parents will drive him to school for the first two weeks. He is keen to return to AFL at the beginning of next season which is 8 months away.** **Surgical Notes: BPTG harvested and ACL reconstructed. Medial meniscus horizontal tear debrided. WBAT + Standard post-operative care.** **Current obs: HR: 52, SaO2: 99% , RR: 14, BP: 120/80 (lying), temperature 37.4, ECG: Normal Sinus Rhythm, Ausc: NAD, pain at rest: 4/10. Panadol 500mg with good effect.** +-----------+-----------+-----------+-----------+-----------+-----------+ | **OBJECTI | | | | | | | VE | | | | | | | -- | | | | | | | Musculosk | | | | | | | eletal | | | | | | | Assessmen | | | | | | | t | | | | | | | (Impairme | | | | | | | nts)** | | | | | | +===========+===========+===========+===========+===========+===========+ | | **Right** | **Left** | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Pain** | Knee 4/10 | NAD | | | | | | (resting) | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Joint | Knee flex | Knee flex | | | | | range** | 65 P1 | 130 R2 | | | | | | | | | | | | **PROM | Knee ext | Knee ext | | | | | (deg°)** | -10 P1 | +10 R2 | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Muscle | **Right** | **Left** | **Muscle | **Right** | **Left** | | strength* | | | strength* | | | | * | | | * | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 5 | 5 | | flex** | | | flex** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **SH | 5 | 5 | **Hip | 5 | 5 | | abd** | | | ext** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Knee | 3 limited | 5 | | flex** | | | flex** | due to | | | | | | | pain | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Elbow | 5 | 5 | **Knee | 2 limited | 5 | | ext** | | | ext** | due to | | | | | | | pain | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Ankle | 5 | 5 | | flex** | | | DF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Wrist | 5 | 5 | **Ankle | 5 | 5 | | ext** | | | PF** | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | | | | | flex** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fingers | 5 | 5 | | | | | ext** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ +-----------------------+-----------------------+-----------------------+ | **OBJECTIVE - | | | | Musculoskeletal | | | | Assessment (Activity | | | | Limitations)** | | | +=======================+=======================+=======================+ | | **No. and amount of | **Kinematic | | | assist** | assessment** | +-----------------------+-----------------------+-----------------------+ | Bed mobility | x 1 mod A | Unable to straight | | | | leg raise and abduct | | | | the right leg onto | | | | edge of bed. | +-----------------------+-----------------------+-----------------------+ | Sitting (static) | (I) | 100% thigh support | +-----------------------+-----------------------+-----------------------+ | Standing up | X 1 SB A with 2 e/c's | ↓ weightbearing | | | | through (R) LL | | | | | | | | ↓ (R) knee ext in | | | | final alignment | +-----------------------+-----------------------+-----------------------+ | Standing (static) | X 1 min A with 2 | ↓ and knee ext in | | | e/c's | final alignment | | | | | | | | ↓ weightbearing | | | | through (R) LL | | | | (approx. 50%) | +-----------------------+-----------------------+-----------------------+ | Walking | X 1 min A with 2 | Stance | | | e/c's x 10m (limited | | | | by pain) | ↓ Heel strike on | | | | right side | | | | | | | | ↓ knee Extension on | | | | right side | | | | | | | | Swing | | | | | | | | - ↓ (R) Knee | | | | Flexion | +-----------------------+-----------------------+-----------------------+ | Stairs | Not yet assessed | | +-----------------------+-----------------------+-----------------------+