CaseMrs Sauls is a 25 year old female, she wasadmitted to UWC’s physio department (hospital)3 days ago. She was diagnosed with a tibialplateau and patellar fractures of the right lowerlimb. The patella was stabilised with k-wires. Sheis in a fixed knee brace which is locked at 10degrees of flexion.
Possible interview questions: Present and past medical history• Intro• How did the injury occur?• How long ago did it happen?• Did you ever have any broken bones or serious injuries before this injury?• Were you ever hospitalised for any other illness?• Were you fit and active before this accident?• Are you coughing at all at the moment?
Social context• Are you working?• What type of work do you do?• Do you play any sports or have any hobbies?• Do you smoke or occasionally drink alcohol?• Are you married, or do you have any kids?
Home environment• What is your home environment like?• What type of surface do you have around your house? Sand or grass or pavement?• Do you have any stairs in or around your house?• Is your toilet inside the house?• Who cleans the house, and cooks supper?
Functional capacity• How are you managing here in hospital?• Can you move around in bed easily?• Can you roll?• Have you been able to sit up out of bed, or walk at all?• How are you going to the toilet at the moment?• Have you ever walked with crutches before, or has anyone showed you how to walk with crutches here in hospital?
In-hospital management• Did the physiotherapist come and see you at all, and what did he / she do with you?• Do you have any questions for me?NOW FORMULATE WHAT YOU WANT TO ASSESSOBJECTIVELY. NEVER TAKE THE PATIENT’S WORDON HIS OWN CAPABILITIES!
Objective assessment: Check chest• Vital signs: Respiratory rate and oxygen saturation within normal limits?• Chest X-ray (when available) any abnormalities?• Ask patient to cough: Effective / ineffective ; productive / unproductive• Auscultate to check for possible basal atelectasis if cough clear• IF NO ABNORMALITIES detected: continue with functional assessment
Functional• Bed mobility• Rolling (if safe)• Moving up and down in bed• Bridge (if using bed-pan)• Sit up over side of bed• Sit-to-stand (with assistance of physio)• Mobilise with crutches if appropriate
Special tests:• Quick test – lattisimus dorsi and triceps strength• Glutes strength(necessary for sit-stand)• Quads strength (assess for quads lag) (contra- indicated in this scenario)• ROM if necessary – ankles – (standing)
Identify patient’s problems in order of priority• Chest clear – thus no chest problem• If chest wasn’t clear - chest always takes priority! If you cannot breath, you cannot walk or do exercises!• Problem: Struggling to sit over the edge of the bed independently• Impairment – fractured patella, unable to flex knee• Restriction: Unable to mobilise
Treatment plan Problem (struggling to sit up) FunctionalImpairment restriction(# patella) (inability to mobilise) Treatment goal