Case Study: Left Total Knee Replacement
Patient (Pt.): Mr. PA, a 75 years old male.
Medical diagnosis: .Primary diagnosis: After care following joint replacement ( v54.81) , Secondary diagnosis : Muscle weakness generalized (728.87)
Physical therapy order: Eval. &treat: Pt has been referred for physical therapy eval and TX post a decline in function in order to improve overall strength, improve balance, and prevent falls.
History:
The Pt had Left Total Knee Replacement (TKR) ON 06/03/2015, following immense pain due to degenerative joint disorder. Pt had been having the pain since little over 5 years, but since the past year it started being unbearable as per the patient.
Past Medical History: Pt has a Past Medical History (PMH) of Degenerative Joint Disease (DJD), back pain, anxiety, depression, GERD and hypothyroidism.
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Plan of care:
Pt requires skilled Pt services to improve strength, increase range of motion and balance, also to be able to perform bed mobility, transfers and ambulation independently and return to PLOF.
Precautions:
Fall risk, WBAT on LLE, Increased Pain on movement of LLE.
PTGoals:
STG to be achieved in 4 weeks:
1) Pt will be able to perform bed mobility where he is able to roll to both the sides with minimal assistance with 25% verbal, visual and tactile cues.
2) Pt will be able to perform functional transfers from bed to w/c where he is able to assist with 75-99% of the transfers, minimal assistance with verbal, visual and tactile cues.
3) Pt will demonstrate optimal level of functional gait performance as he is able to walk with RW with minimal assist ( 25%) for 50-75ft.
4) Pt will be able to move his L knee from 0-90degree from 23-75degree and be able to sit in a chair with 90degree hip and knee flexion with no to minimal
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