- Explain the diagnosis and secondary diagnoses in lay terminology as if you were explaining to the patient.
- How will the diagnosis and secondary diagnoses impact your care? Are there special precautions or contraindications associated with the disorders?
- Describe this patient’s impairments as well as activity limitations and participation restrictions.
- How will the personal characteristics of the individual impact your care?
- Is there anything that is unclear about the care plan that will need further clarification? What communication will be necessary with the physical therapist?
- What information would be important to review from the chart for this particular patient?
- Will you need to consult or collaborate with other health care professionals regarding the patient’s care? If so, with who, and in what manner?
- Attachment 1
- Attachment 2
Facility: St. Mary’s Out-Patient Clinic 95;. Right hip PL THAMD Orders: WBAT on right, PL hip precautionsAge: 75 S: Patient is a 75 year old female who lives with her husband in a ranch style home with two step entry. Shehas been independent with all ADLs prior to surgery and other medical history is unremarkable. She had a THA surgery two weeks prior and is now referred for out-patient physical therapy to improve strength and function.Patient rates pain as 3-4/10 with movement, but states the pain has improved signiﬁcantly while walking.Patient able to recite hip precautions. 0: Cognition: Alert and oriented x 4Posture: Patient stands with hips and knees in slight ﬂexionGait: Patient ambulates modiﬁed independent with a walker, slight Trendelenburg gait on right. Bed mobility and transfers: SBA for transfers and minimal assistance for transfer from sit to supine to liﬂlower extremity. Patient performs activities while maintaining hip precautions without cuing. Standing Balance: Patient stands in bilateral stance without assistive device in parallel bars 30 sec with SBA Incision: There is an incisional wound approximately 8 inches in length over the lateral hip area, with slighterythema at proximal incision edge Palpation: Tenderness over the lateral hip area generally. Circumferential Measurements: There is dependent edema in the right lower extremity measured as follows: Right LeftCircumference around malleoli 28 cm 24 cmPassive Range of Motion Right Hip Left HipExtension -10 0Flexion WFL m Other ROM tests deferred due to THA Strength: Right hip grossly 2+/5 with cfo pain upon active motion, left hip 3+l5 A: Problem List:1. Right hip pain