2. HEALTH STATUS
• mr.Xyz is a 15 yr. old male , with no known comorbidities
presenting with a chief complaint of pain in left elbow during
movement and unable to completely bend and extend the left
elbow since 2.5 months. He has a history of fall from bed and
supracondylar fracture which was managed conservatively.
3. BODY
STRUCTURES
integrity impaired Source of
info
Problem
description
qualifires Clinical reasoning
Str. Of the
nervous sys.
str,. Of the
eye ear
Str. Of voice
and speech
Str. Of cvrs
and
immunologica
l sys.
Str . Of
digestive and
metabolic sys.
Str. Od
genitourinary
and
reproductive
sys.
Str. Related
to
movement
-left
humerus
Technical
investigation
s
Discontunity
seen in
supracondyl
ar region of
humerus
Q1-
2[moderate]
Q2-
5[discontiuty
]
Q3-2[left]
There was a fall
from bed on left
elbow
Causing trauma
which led to
exertion of
excessive forces
on the left
humerus
[supracondylar
region]
Result in break in
continuity of
bones.
4. BODY FUNCTIONS
Integrity impaired Source of
info.
Problem
description
qualifier
s
Clinical reasoning
Mental
functions
Voice and
speech funct.
Functions of
cvrs,hemmatol
ogical ,
immunological
Functions of
digestive and
metabolic syst
Genitourinary
and
reproductive
functions
Sensory function
and pain
history Nrs
On activity-6
On rest-4
2
moderat
e
Due to fall from bed
on left elbow
There is traumatic
injury
Humerus fracuture
Managed
conservatively
Release of
inflammatory
mediators –
bradykinin&
cytokinin
5. Sensitize specific
pain receptors nerve
endinds present in
body tissue initiated
specific nerve to
spinal cord
It stimulates 2nd
order pain receptors
relays the message
through higher
centers including
thalamus
Pain perception
6. ROM of left
upper extremity
Muscle power
Clinical
examination
Clinical
examination
Rom
Flexion-0-90
Extension-90-0
MMT
Flexors-2
Extensors-2
2
3
Traumatic injury to
humerus managed
conservatively
Leads to immobilization of
elbow joint
Tightness of muscles of
flexors and extensors
Decreased ROM
Supracondylar humerus
fracture
Immobilization leads to
weakness of muscles
Reflex inhibition of
muscles
Decreased in number of
sarcomere
8. ACTIVITIES AND
PARTICIPATION
CAPABILITIES ACTIVITY
LIMITATION
AND
PARTICIPATIO
N
RESTRICTION
CAPACITY QUALIFIER PERFORMANCE QUALIFIER
Learning &
applying
knowledge
General task
&demand
Communicatio
n
Domestic life
Interpersonal
relations
Major life
Mobility
-lifting and
carrying object
with left hand.
Self care
-dressing
-eating
Patient faces
moderate
diificulty in
lifting objects
for long time
due to pain
and reduced
strength.
Patient is
unable to
dress up and
eat on his own
using left
hand due to
pain &
reduced
2(moderate)
3(severe)
He avoids
lifting objects
with left hand
& uses his
right hand.
Needs
assistance
from his
relatives.
1(mild)
1(mild)
9. CONTEXTUAL
FACTORS
Environmental
factors
Source of
information
Facilitatorbarrier Description Qualifier
Products and
technology
Attitude
Support &
relationship
Services,systems
&policy
Patient history
Patient history
Patient history
Facilitator
Facilitator
Facilitator
Facilitator
Medications &
physiotherapy
treatment
facilitates
recovery.
Cooperative and
positive attitude.
Supportive
family.
Receives charity.
+3(severe)
+2(moderate)
+3(severe)
+2(moderate)
Personal factors Source of
information
Facilitator/barrie
r
Description Qualifier
Age
Comorbidities
Coping style
Patient history
Patient history
Patient history
Facilitator
Facilitator
Facilitator
Young age aids
recovery
No known
comorbidities
Positive and
relaxed
+3(severe)
+3(severe)
+2(moderate)
