Nursing Case Study
DOI: 2/2/2016. Patient is a 59-year-old female certified nursing assistant who sustained injury to her low back and right knee while transferring a patient. Per OMNI entry, she was initially diagnosed with right knee contusion/strain and lumbar sprain. She is status post right knee arthroscopic medial meniscectomy, medial condyle abrasion arthroplasty major synovectomy/3 compartments and lateral release on 07/31/16.
Per the PT note dated 10/17/16, patient is doing well with the exercises. However, pain in her right knee continues to be a limiting factor. She is much improved functionally and her pain has lessened Stretching to the right knee into either flexion past 120 degrees and extension past -2 are painful and limited. Patient has attended 12 visits. …show more content…
Based on the progress report dated 11/17/16 by Dr.
Mcclurg, the patient presents for medications and therapy follow-up. Patient wishes to discuss: "Why I am having numbness to the lateral aspect of the right foot?." She had new medical problems diagnosed since her last visit. she now reports numbness to the right foot. No diagnostic tests have been performed in the interim. Therapy provided since her last visit includes physical therapy. Patient has benefitted from therapy by decreasing pain. There has been no change on the use of medications since the last visit. Medication is helping. Pain without medications is rated as a 9/10. Pain with medications is rated as a 5/10. Medications help by decreasing pain. She is out of medications and is requesting a refill at this
time.
Braces/supports are being used for this condition. Patient did not receive an injection on her last visit. She experiences pain to low back, right hip/thigh and right knee/leg. Pain is described as stabbing, achy and burning. Pain is present 75% of the time (frequently). Symptoms are improved by resting, icing, creams and medications. She is not gainfully employed at this time. The employer has no modified duties available. Functional gains noted with treatment include improved motion.
IW was diagnosed with complex tear of medial meniscus of the right knee, sprain of other parts of lumbar spine and pelvis, and low back pain.
Response to therapy has been good. patient is encouraged with gains being made. Improved function and functional restoration are expected with additional therapies. Further gains can be achieved by extending therapy. A course of therapy was recommended.
He was given a prescription for Ibuprofen 800mg.
Per verification from the provider’s office, the IW has had 24 sessions to date for the right knee and no PT was done for the back.
Per the adjuster’s notes, patient has had 36 post-operative PT sessions for the right knee. Current request is for 8 Physical Therapy Visits for the Lower Back and Right Knee between 12/6/2016 and 2/4/2017.
Per the PT note dated 10/17/16, patient is doing well with the exercises. However, pain in her right knee continues to be a limiting factor. She is much improved functionally and her pain has lessened Stretching to the right knee into either flexion past 120 degrees and extension past -2 are painful and limited. Patient has attended 12 visits. …show more content…
Based on the progress report dated 11/17/16 by Dr.
Mcclurg, the patient presents for medications and therapy follow-up. Patient wishes to discuss: "Why I am having numbness to the lateral aspect of the right foot?." She had new medical problems diagnosed since her last visit. she now reports numbness to the right foot. No diagnostic tests have been performed in the interim. Therapy provided since her last visit includes physical therapy. Patient has benefitted from therapy by decreasing pain. There has been no change on the use of medications since the last visit. Medication is helping. Pain without medications is rated as a 9/10. Pain with medications is rated as a 5/10. Medications help by decreasing pain. She is out of medications and is requesting a refill at this
time.
Braces/supports are being used for this condition. Patient did not receive an injection on her last visit. She experiences pain to low back, right hip/thigh and right knee/leg. Pain is described as stabbing, achy and burning. Pain is present 75% of the time (frequently). Symptoms are improved by resting, icing, creams and medications. She is not gainfully employed at this time. The employer has no modified duties available. Functional gains noted with treatment include improved motion.
IW was diagnosed with complex tear of medial meniscus of the right knee, sprain of other parts of lumbar spine and pelvis, and low back pain.
Response to therapy has been good. patient is encouraged with gains being made. Improved function and functional restoration are expected with additional therapies. Further gains can be achieved by extending therapy. A course of therapy was recommended.
He was given a prescription for Ibuprofen 800mg.
Per verification from the provider’s office, the IW has had 24 sessions to date for the right knee and no PT was done for the back.
Per the adjuster’s notes, patient has had 36 post-operative PT sessions for the right knee. Current request is for 8 Physical Therapy Visits for the Lower Back and Right Knee between 12/6/2016 and 2/4/2017.