A 41 y/o young man in a cancer unit with Urinary Tract Infection (UTI)

HPI:

Physical Therapy was consulted for a 43-year-old African-American male who was admitted to the cancer ward for anorexia and stomach pain.
The consult was generated because he said he felt out of energy at time of admit. He was also found w/SIRS due to UTI. Gastroenterology was consulted & he was awaiting EGD & Colonoscopy.

Physical examination:

Observation: Young African American male, appearing stated age, of medium stature, thinly built, supine in bed, in no obvious distress.

Vitals: BP: 114/74 supine; HR – 79; RR – 14; SaO2 – 98% on RA.

Systems Review:

Cardiac: Heart Sounds S1, S2. No murmurs, no bruits.

Lungs: CTAB

Motor: UEs – 5/5. LEs bilaterally 0-1/5.

Sensory: Intact to CT/JPS bilaterally

Reflexes: DTRs – 2+ in UEs’ ; 0-1+ in AJ & KJ.

Coordination – FTN is normal; No tremors. HST – Unable on command.

Function – Able to sit up – needed hands to assist legs to EOB. Able to scoot in bed in sitting using hands. Unable to stand or too afraid. Stated that the weakness had become this acute since last 2-3 hours after physician rounds in the morning.

Assessment:

At this time, please list every possible reason you can think of of WHY do you find the patient in the current situation?

To do this, you will need to have a verifiable PROBLEM LIST.

So, What are the PROBLEMS? >>> WHY are the problems present (i.e. Causation).

You may or may not need to request specific confirmatory tests – but you have to be clear in your mind on what specific test you would want in this situation.

If you can arrive at plausible WHYs, you have solved the problem. The treatment of the underlying CAUSE (the so called “WHY”), is the resolution of the patient’s symptoms.

Everything else as a part of PT is supportive measures – Education, and Prophylactic.

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