Once again another problem that i need guidance on all the data to put in order to eval and implement a PT evaluation.
EC Case 2
70 y/o female admitted secondary to fall at home secondary to syncopal event, (-) fractures. Medical w/u reveals dehydration, Rx with IV fluids.
PMH significant for MI, CAD, CHF, NIDDM, chronic Afib, duodenal ulcer, chronic renal insufficiency.
Meds: digoxin, lasix, coumadin, nitro prn, KCL, zantac
SH: Lives alone in third floor apartment. No local family for support.
Orders are "PT eval and treat pending discharge home soon"
hemodynamics: BP supine 110/70, sitting 100/60, standing 100/60, ambulates 100 feet 110/65; HR response 85 to 110 irregularly irregular. Heart sounds S1, S2. c/o fatigue and shortness of breath.
What factors influence your decision regarding discharge recommendations? Do you have enough information now? If so, justify your decision. If not, justify what information you require and how it will influence your decision.
Discharge recommendations should be based upon:-
(1) Evaluation of patient's level of function - strength, ROM, coordination, balance and mobility.
(2) Assessment of patient's home environment - safety, accessibility, her ability to get around in the home without injuring
herself, need for equipment to optimize function and safety in the home.
(3) Evaluating patient's self-care skills such as ...
Case involving PT evaluation and discharge recommendations for a patient with multiple cardiopulmonary problems.