PT616 Comprehensive Capstone

Case Study 1 for Discussion

Mrs. Harkins is a 74 year-old homemaker who currently cares for two of her four grandchildren during the day
while their parents work. Her primary care physician referred her to you for balance and gait training after her 6
month checkup appointment with him yesterday. The telephone/verbal referral from the physician’s nurse was
“examine and treat”. You are seeing Mrs. Harkins in an outpatient therapy setting.

1. Refer to the patient’s responses on the initial intake form that she completed while in the PT waiting
area and the additional information below that was gained during the history/interview:

Mrs. Harkins reports that she was involved in a car accident 7 days ago in which she lost consciousness and was
taken to the ER by ambulance. About 45 minutes after arriving in the ER, she regained consciousness. The
patient was told by a nurse and a physician that she had been in an accident and was in the hospital. Her husband
says that she immediately asked about her grandchildren, forgetting that they had not been with her in the car.

Mr. Harkins (patient’s husband who is a bit of a medical junkie) tells you the following information from the ER
and from his wife’s medical history:
 Initial Glascow Coma Scale score in the ER: 14 (4, 6, and 4 on eye opening, motor response, and verbal
response respectively)

 DVT : currently on low dose coumadin; hospital admission 9 months ago to control bleeding subsequent to
dental work; continues under the care of her primary care physician (PCP) for regulation of coumadin levels
which are not yet stable. Her appointment yesterday was a regularly scheduled checkup for general health
and coumadin levels.

Mrs. Harkins reports, during her most recent visit to her PCP yesterday, that she has experienced fatigue,
dizziness, and unsteadiness when walking.

2. Will you gather any other information during the general health history?
a. If so, what?
 Depression - Have you had any life changes recently? Is your doctor aware of your symptoms?
Have you ever received any help for your depression? Has she been sleeping more than usual?
(this may be the cause of her fatigue) Son died about 10 years ago. Did receive help, went to
counseling, received medication but hasn’t received anything the past 8 years.
 Fatigue, dizziness, & confusion - what makes it worse, better? Is it constant, intermittent, etc?
Have these symptoms affected her daily routine and/or has she had problems taking care of her
grandchildren? She can go all day, very active with community but is tired when she lays
down at night - overall tiredness. Hasn’t noticed any patterns with the dizziness but could not
figure out particular time that made her more dizzy.
 Taking care of 2 grandchildren - ask if she has any help taking care of them, how old her
grandchildren are (wanting to know if they are able to help in any way or able to call for help
if needed -- want to make sure that everyone is being safe) 2 and 4 years old but doesn’t have
any problems with them.
 Medications - I would ask her if her doctor is aware of what she is taking? How often does she
take them? Centrum Silver - several years, Statin - 10 years, Coumadin - 5 years. Does she
have any side effects that she is aware of?
 Ask her about her chemical dependency that she marked in her past medical history -- how
long ago? What was she taking? Has she had any alcohol or drugs recently? Is she doctor
aware because this may be contraindicated with the use of alcohol if she is still taking. Not
currently taking but has 1 glass of wine with dinner.
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  Ask about her balance issues -- is this from her fatigue or dizziness or is it from weakness,
coordination problem, perception/visual problem. No balance issues before the MVA.
 Ask about her Polio and if she has had any issues with muscle strength in muscles that were
previously affected? Had as a child and hasn’t had any residual deficits, occasionally will have
a toe drag when she gets tired. Never had respiratory issues, had to use braces on BLE when
she was young.
 4 pregnancies but only 3 live births? Had a miscarriage
 Ask if she has ever seen a doctor for her neck/back problems -- have you ever seen PT for this
problem? Does this affect your ability to take care of your grandchildren? Comfort for sleep,
neck pillow is from doctor.
 Ask about her pneumonia -- is this a recent issue? How long ago? Last year. Fully treated and
resolved.
 Ask about her thyroid problem -- is her doctor aware? Is she taking any medications for this
issue? Hypothyroidism or hyperthyroidism? No meds, doctor told her it was enlarged thyroid
but it’s fine.
 Ask about her UTI -- how long ago did that occur? Did you see a doctor? Have you had more
than one UTI?
 Level of education? Master’s Degree in teaching
 When did she get pacemaker? 5 years ago because heart was fluttering
 Lab values were normal - no imaging were done because she went to a small rural hospital
 No pain
 No numbness or tingling in her hands or feet
 Had fallen a couple of time in the past year but blamed tripping over rug and dog
 Has complained of headaches since accident
 Hasn’t had any problems sleeping and can go to sleep fairly quickly. Doesn’t sleep long
periods of time - wakes up at 4 am.

Dizziness - Endocrine, Neuro, CVP

Fatigue/Drowsiness - CVP, Neuro, Endo, Psych
Confusion - Endo, Neuro, Psych
*CVP - has diagnosis by Dr. and Dr. is aware of pacemaker = MONITOR
*Neuro - Polio would be in Neuro system but not the cause of dizziness and confusion =
SCREEN
*Endocrine - Thyroid (hyperthyroidism) could be the cause of fatigue = MONITOR
*Psychological - Depression, fatigue because known = MONITOR

3. During your ROS and the screening process, will you conduct screen/s of any of the specific systems?
Use your algorithm and justify your answers.
a. If so, which ones? What are the specific questions you’ll ask?
 Neurological - Dizziness, unsteadiness when walking, balance problems/falls, and recent
confusion could all be due to an underlying neurological problem. It could also just be due
simply to her age or other problem that is already diagnosed but it is important that we rule out
any neurological issue because of her age.
o Have your noticed any problems or changes in your sensation in your hands or
feet? Intact, reflexes normal
o Have you noticed any changes in your memory or your ability to remember daily
routine tasks? None except time surrounding accident
o Have you had any changes in your vision? None
o Have you had any changes or increased difficulty with your hearing? None
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 o Muscle atrophy? Some weakness sometimes and feels shaky when she stands up
sometimes, no paralysis or tremors
o Seizures? None
o Do you have balance problems only on flat surfaces or uneven terrain as well?

VITALS
Supine: BP 120/78
Sit: BP 114/76; HR 75; RR 18
Stand: BP 110/76; HR slightly decreased
3 mins in standing: BP 118/79; HR recovered

4. What physical therapy tests and measures will you conduct? Prioritize your examination.
AROM/PROM: WFL
MMT: R side 4-5/5 t/o; L side 4/5 UE; LLE 4-5/5
Gait Analysis: in swing  flexion in hip, knee, and ankle; compensated with hip ER, AB, and R trunk
lean. Stance = LLE push knee in ext. for stability but had been walking like that since she was a child
Posture: L knee hypertext, ant. pelvic tilt, forward head, L pelvis elevated,  kyphosis, C curve in L
spine with concavity toward Left
Sensation - pin prick/light touch: Normal
Berg Balance Test, Tinetti: didn’t do
Timed Up and Go: 18 sec. and got dizzy**** immediately upon standing
Finger-to-nose test: no problems
Homan’s: negative
Bruising: Arms, legs, and one on her knee
Alert and Oriented:
Follow commands: difficulty following commands, difficulty finding the right words
6 minute walk test: good to do for fatigue but didn’t do
3x sit to stand: unsafe because of dizziness
Subjective test about fatigue: tired and wanted to go home and take a nap

5. Are there any considerations based on the patient’s demographic information (race, culture, etc). This
patient is at risk for HTN and hyperlipidemia due to her age and ethnicity (Hispanic), which were
indicated in her health history. Also, this patient is at risk for heart disease due to family history (father)
of heart disease.

6. Just to think about now and answer later……Based on the responses (that will be provided in class),
what is your decision? Justify your decision…
Treat Treat and Refer REFER

Dizziness, confusion, memory loss - Treat & Refer to Neurologist. Doesn’t have a neurologist so call
PCP 1st and talk to them about symptoms that happened since accident. Make them aware and ask what
they think you should do. Check with PCP before treating patient.
 No imaging done at hospital
 Not normal baseline
 Loss of consciousness
 Forgot to tell physician about dizziness and confusion

Patient was sent back to the PCP that day and they sent her to the ER for imaging. Patient had a slow
bleed since the MVA and deteriorated quickly.