PT-diagnosis - heeelp...

[nadja66]

hey there..

im new in this forum and i really could use some of your help..
im a student at a swiss school and im about to do my bachelor..at the moment im doing an internship abroad..
for my school i now have to write an essay about one of my patients. among other things i have to write a PT-diagnosis, a report to the doctor as well as one to the physical therapist who will take over my patient. unfortunately i have no idea how i have to write these things..and the people working at my hospital couldnt really help me either, cause they didnt do the bachelor, just a german education..and on top of that..the only bachelor in the house is on holiday for the nex for 4 weeks..

id woud be really kind and i would really appreciate it if you could give me some hints about how i have to write these things..

by the way.. i have a patient who had a hip surgery (got an artificial implant) 6 days ago. therefor the patient now has problems with the rang of motion of his hip-movements as well as with the strenght. furthermore he has a big swelling around the whole thigh..

thanx alot..

greets

[nwobhm]

well im a student also from south east asia (philippines) well firstly i hope im not too late to help you.
here in our country Pt dont have as much freedom as you guys there(due to our stupid law and lazy congressmans) so they dont let us call it pt-diagnosis hence it is reffered to as pt-impression.
well the main thing about pt-impression/diagnosis is your analysis and explanation on what is your patients problem and is condensed in a one full pack sentence/paragraph.
it is usually comprised of participation restriction, activity limitations, impairment then the medical condition.
I usually make it AL--> PR due to I 2ndary to med diag.
ex.
"inability to walk makes the px unable to perform role as a parent due to weakness of the (R) knee extensors 2" to L3 palsy."
I usually have a prob bec. there is no general agreement on how it should be done. just remember its purpose is to communicate what ur patients problems are...

[nadja66]

hey there..

no youre not to late..thanx alot..

[gharris29]

This may be far too late to help, but it may come in useful another time, you need to be able to give them quantitative things to compare, so by what degree is movement limited in flexion,extension, etc, something they can use to compare to what they are seeing now, it gives a base line of where the patient is and it is therefore more accurate to see progression, also it is important to say what position the movement is being measured in, e.g there may be decreased hip flexion in standing, but unless you say that it was measured in sanding they may look at it in supine lying, in which case the rom may be different due to the different positional factors affecting the joint,muscles,etc... oh well hope this helps, i do blabber on i'm afraid,i hope you get the jist.
Georgina