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    Calmette Hospital

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    ខៃសិញ- Khaisinh
    This clinical reasoning form summarizes the treatment for a 35-year-old man who suffered a left elbow fracture in a traffic accident. He has pain and stiffness in his elbow. Physical examination found limited elbow range of motion and muscle weakness. X-rays showed a healed fracture with callus formation. The diagnosis is a left olecranon fracture. Treatment goals are to reduce pain, increase range of motion, and improve muscle strength over 3-6 weeks with physical therapy including soft tissue massage, stretching, and passive mobilization exercises. Progress will be evaluated using pain scales, range of motion measurements, and muscle strength tests.

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    Calmette Hospital

    Uploaded by

    ខៃសិញ- Khaisinh
    38 views3 pages
    This clinical reasoning form summarizes the treatment for a 35-year-old man who suffered a left elbow fracture in a traffic accident. He has pain and stiffness in his elbow. Physical examination found limited elbow range of motion and muscle weakness. X-rays showed a healed fracture with callus formation. The diagnosis is a left olecranon fracture. Treatment goals are to reduce pain, increase range of motion, and improve muscle strength over 3-6 weeks with physical therapy including soft tissue massage, stretching, and passive mobilization exercises. Progress will be evaluated using pain scales, range of motion measurements, and muscle strength tests.

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    This clinical reasoning form summarizes the treatment for a 35-year-old man who suffered a left elbow fracture in a traffic accident. He has pain and stiffness in his elbow. Physical examination found limited elbow range of motion and muscle weakness. X-rays showed a healed fracture with callus formation. The diagnosis is a left olecranon fracture. Treatment goals are to reduce pain, increase range of motion, and improve muscle strength over 3-6 weeks with physical therapy including soft tissue massage, stretching, and passive mobilization exercises. Progress will be evaluated using pain scales, range of motion measurements, and muscle strength tests.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views3 pages

    Calmette Hospital

    Uploaded by

    ខៃសិញ- Khaisinh
    This clinical reasoning form summarizes the treatment for a 35-year-old man who suffered a left elbow fracture in a traffic accident. He has pain and stiffness in his elbow. Physical examination found limited elbow range of motion and muscle weakness. X-rays showed a healed fracture with callus formation. The diagnosis is a left olecranon fracture. Treatment goals are to reduce pain, increase range of motion, and improve muscle strength over 3-6 weeks with physical therapy including soft tissue massage, stretching, and passive mobilization exercises. Progress will be evaluated using pain scales, range of motion measurements, and muscle strength tests.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    - Name: Mr.

    Bun Heab
    - ID: BSP220013 CLINICAL REASONING FORM B
    - Calmette Hospital

    This is to be completed after the patient physical assessment and treatment.

    1. Describe the patient (age, gender, occupation, brief history of main


    complaint, relevant past history if any)

    -Mr. Em Kim Srun in the ages of 35years old.


    He works as a Marketing and living in Phnom Penh.
    He feel pain on the left of elbow 6/10 in left
    Elbow flexion caused by traffic accident 12.09.22.
    Doctor gave painkiller and allowed him to do
    exercises by himself at home.
    He was operation more than one and half month by
    K.wire on left olecranon.
    After that, he worry about his elbow bending because
    he feel hard to move his hand and he tried 1week ago.
    Then, he decided to come to get Physiotherapy service
    at Calmette Hospital.

    2. BODY CHART & INTERPRETATIO


    a. Complete the body chart and clearly label each symptom location
    (VAS, associated symptoms, relationship)

    - Tightness Pain 6/10 during bending.


    - Pain going down 3/10 when relaxing 5minutes.

    3. INTERPRETATION OF THE PHYSICAL EXAMINATION


    3.1 Which specific physical examination findings are related
    with the patient’s complaints/functional limitations?
    Active (degree) Passive (degree)
    - AROM: Left Elbow Flex 80 90
    Elbow Exten Full Full
    Supination 35 40
    Pronation 40 50
    - Muscles M+ Left Elbow Flex: 3+/5, Elbow Exten: 3/5, Left Elbow Mucles contracture.
    - Sensory: Good

    3.2 What medical or radiological investigations have been carried out?


    - X-Ray: 30.09.22
    What are the main findings and are they relevant to the patient’s
    disorder?

    - X-Ray: With strong callus on Olecranon

    Will the radiological findings influence your treatment


    plan? State your reason.
    - X-Ray: Is much important when stretching joint.
    - Especially, during Elbow Flex and Exten.
    - To avoid bad things.

    4. ANALYSIS OF THE DISORDER

    4.1 What is the patient’s diagnosis?

    - Left Olecranon Close #

    4.2 What is the expected prognosis?

    - That is Good

    State your reasons.

    - Because I have the objective assessment to evaluation the improving ROM and
    muscles strengthening. The patient do exercises at home. It will take 3weeks to
    improve. Pain 6/3 when stretching and pain down 3/10 when relaxing. So I could
    rehabilitation on his elbow joint.
    4.3 List the patient’s problem list (Max 3).

    - Tightness and Pain 6/10 on left elbow and no numness referred to wrist
    - Stiffness left elbow in flexion.
    - Hard to bending and extension left elbow.

    4.4 List your STG and LTG for this patient (patient centered approach) and
    the time frame to achieve them.

    - STG: - Reduce pain 6/10 to 3/10 right elbow in (3weeks)


    - Increase ROM left Elbow Flex 80degree to 95degree (3weeks)
    - Improve Muscles strengthening in elbow flex 2/5 to 3/5 (2weeks)
    - Improve Muscles strengthening in elbow flex 3/5 to 4/5 (2weeks)
    - LTG: - Ability to move his hand more easily (6-12weeks)
    5. MANAGEMENT AND EVALUATION

    5.1 What is your treatment for Day 1?

    - Soft tissue technique (5-10minutes)


    - Stretching muscles left elbow 20 to 30s, 5 to 10 moments.
    - Stretching Joint 1 to 3 minutes in 5-10 movements.
    - Passive Mobilization 30 movements 10 moments relax 1minute.

    5.2 What asterisk signs would you use to evaluate your treatment
    outcome? (you may include outcome measures)

    - Reduce pain (Pain Scale)


    - Soft tissue release (Muscle length and compare with healthy side)
    - Improved ROM (Goniometer)

    5.3 List your plan for the next session assuming that the patient is
    a) better

    - Observation about treatment with the same technique and add more exercises.

    b) same

    - Re-evaluation the assessment and add more exercises.

    c) worse

    - Re-evaluation and change the technique with according to Physical


    Examination.

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