Introduction

Patient details:

Gender: female Age: 86 Date of admission:

Situation:

Presenting Problem:

. Her main problem is bilateral leg oedema. Due to this, she is not able to lie down on the bed and she reports that she normally sits on the chair and sleeps on the chair. She describes 10/10 pain at rest and 8/10 pain after taking a painkiller.  She is difficulty in swallowing big tablets so she reports that she splits in half and takes. She has emphysema which leads to difficulty with walking more than 15 meters without rest due to shortness of breath. She is currently suffering from MRSA in sputum.

Social History:

She lives alone in a single story house which does not have any stairs. Her daughter who lives 10 minutes away from her house takes care of her. There are shower chair and rail in bathroom for her safety. Baptist care assists her with house cleaning and shopping every two weeks. She does not smoke and drink alcohol at all. She reports that she normally uses an oven to heat up the food.

Present during admission (?)

Past History:

Hypothyroism in 2004

Left breast cancer (Left Mastectomy) and in Metastasis lung – RL2 lesion

Type 2 Diabetes in 2006

Osteoporosis in 2007

Car accident in 2010

Ex-smoker

Assessment (what are the patient’s main problems/medical, social, physiotherapy) (?)

In terms of medical aspect, his oxygen levels were 88% on 2L oxygen. With respect to social aspect, she has limitation on DADLs and PADLs. The physiotherapists plan to

Recommendations

Measuring range of motion (leg flexion and extension and ankle dorsiflexion and plantar flexion) and gait parameters analysis should be done to assess precisely. To improve walking ability and balance and eventually self-care ADLs, regular sit to stand exercise is needed to strengthen lower limb muscles. In addition, emphasizing the importance of exercises and how she has to handle for shortness of breath instead of avoiding walking for long distance due to being afraid are also needed. Walking around the hospital twice a day, as usual, might be done for mobilization.