Comprehensive Assessment of T.E.72 for Mobility Improvement
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Understand the case of T.E.72, a male post-AKA patient with DM type 2 and HPN, to assess his mobility needs. Gather past medical and social history, medication details, living conditions, and functional limitations to recommend appropriate tests and measures for improvement.
Comprehensive Assessment of T.E.72 for Mobility Improvement
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Presentation Transcript
Name:T. E. 72 /Male Diagnosis: DM type 2 obese s/p AKA (Dec 2008), HPN st. 2 good control s/p cataract surgery (2004) Date of PTIE: March 16, 2009
Chief complaint: “Di ako makalakad ng mag-isa” • HPI: • Underwent transfemoral amputation of (L) LE d/t presence of arterial ulcers. • Confined for a couple of days • Further subjective information to follow...
Past Medical History: Cataract surgery (2004) HPN st II diagnosed since he was 18y.o. Diabetes since 1999 Congestive heart failure 1970’s Smoking history: started 16y.o. Stopped 1970’s Alcoholic beverage drinker
Family Medical History: Diabetes on both sides HPN, siblings • Present Medications Simvastatin Tramadol Metoprolol
Personal / Social / Environmental • Retired electrician • Married with 2 children: 19 & 29 • Accompanied in the house by wife, children, and “pamangkin” • Likes to play chess and cards, read newpaper, and answer puzzles
Lives on a two-level house • Bedroom on the first level • Bed approximately at the height of his knees: located approximately 4m from the bathroom and 1m from the door of the house • Needs to negotiate a two-step stair upon entering the house • Most of the time, pt is on his wheelchair
Any pertinent information that you might want to know about the patient....
OI W/c borne with caregiver propelling the w/c Posterior skin flap Trophic skin changes on the (R) anterior, lateral, and posterior tibial area
Palpation Grade 2 tenderness on the posterior aspect of the stump
MMT • Sensory Ax • Anthropometry • ADL Analysis