Nursing Case Report Sample

Subjective: The patient is a 31-year-old female involved in a motor vehicle accident on May 8, 2014. Initially she felt pain in her right foot, in which her foot got stuck under the gas paddle. Once she got out of the car to walk, she felt pain in her right thigh. She went to the emergency room at Fort Washington. No x-rays taken. She was given crutches to be nonweightbearing on the right extremity. She thought that she might have fractured her right leg, uncertain of which bone. She was given a prescription for Percocet and a muscle relaxant. Medications helped with pain. She saw her primary doctor, was examined, and told that her leg was bruised and she was taken out of work. She was advised to continue with medications. She
had a followup with her physician three times at one point having an x-ray of her right knee and told she had fluid on her knee. She saw Dr. Quraishi for followup. An MRI was ordered, the patient does not know results, told her knee was bruised and referred to PT. She notices increase in pain perception with standing. Every morning the knee is swollen and decreases with movement. She has had a history since the accident of falling while holding her baby. Prior to the fall, her knee cracked and then popped. She has difficulty lifting her baby. She is also starting to have discomfort in her left knee because of increased pressure on that side. She has difficulty with driving and it increases pain in her knee. Her vehicle is automatic. She gets temporarily relief with the use of ice, heat, trying to actually pop the leg by moving it in different direction until it pops and massage. No structured exercise program. She works as a social worker in a single building. Job-related activities require walking, transporting residents, pulling relatives up and down in the van, lifting food distribution up to 1000 pounds. No breaks p.r.n. She has continued to resume job-related task. She rates her pain on a scale of 1 to 10 when sitting as an 8. Her goals for physical therapy are to stop falls and to resume exercises. She takes medications for weight loss. Past Medical History: In 2008, motor vehicle accident with no injury. Objective:
Gait: Antalgic.
With stance on the right, complains of pain in the right lateral hip, anterior thigh. Her right lower extremity is externally rotated and she actually limps. She has pain in her left hip with stance on the left.
Steps: Step up on the left, complains of popping in her right lateral knee, down on the right she limps. Down on her right, complains of pain in the left lateral legs Steps up on the right with effort, complains of pain in the quad muscle and anterior knee. Down on the left with effort, complaint of pain in the right anterior knee.
Range of Motion: Active range of motion, right knee extension is -3 degrees, left is 0 degrees. Knee flexion on the right is 90 degrees with complaint of pain in the right hip, superior knee, and inner thigh. The left is 120 degrees.
Muscle Performance: Manual muscle test, hip flexion on the right is 5-/5 and left is 5/5. Hip extension on the left is 5/5 and on the right is 4/5 with complaint of discomfort in the lateral hip. Hip abduction on the right is 4/5 and left is 5/5. Hip adduction on the left is 5/5 and on right is 3+/5 with complaint of discomfort in the right lateral hip. Knee extension is 5/5, knee flexion on the left is 5/5, the right is 5-/5 with complaints of tightness in the
knee.
Palpation: Tender superior and lateral to the patella on the right.
Posture: Decreased lumbar lordosis stance with right knee flexed.
Special Tests: No special test at this time.
Treatment: Discussed the use of heat and ice. Instructed and performed x5 each with proper technique, straight leg raise, heel slide with quad sets, supine hip abduction and adduction, ankle dorsiflexion, quad set, and gluteal squeeze. Given a copy of exercises for home exercise program. Also discussed benefit of using an assistive device to take stress off of the knee joint during ambulation, especially because job-related activities require a lot of ambulation and the patient’s gait is antalgic. Modalities, ice to right knee with electrical stimulation high rate set for pain superomedial, superolateral, inferomedial, and inferolateral right knee x15 minutes. Assessment: The patient presents for physical therapy evaluation with above-documented function with pain in her right knee status post traumatic event, motor vehicle accident. X-ays showing small effusion in the right knee. The patient has had MRI and would benefit from test results to assess condition of soft tissue that support the knee. Goals:
Short-Term Goals: x4 weeks:
1. Decrease soft tissue inflammation to promote healing with a reduction in pain perception from 8 to
4.
2. Restore pain-free knee range of motion, right knee extension to 0 degrees and knee flexion at least 15 to 20 degrees.
3. Increase strength of the muscles that support the knee at least half a grade with carry over to improve tolerance for stance weightbearing during the gait cycle, especially on the right.
4. Proper demonstration and understanding of therapeutic exercises.
Long-Term Goals: x6 weeks:
1. Independent home exercise program, transitioning to the community.
2. Restoration of functional range of motion and strength with carryover to ability to participate in ADL and job-related activities per previous level of function including demonstration of normal gait sequencing on level surface and steps. Plan: Modalities; ice, heat, stimulation, ultrasound, therapeutic exercises for range of motion, flexibility, PRE, home exercise program, gait training on level surfaces steps.