Luisa has completed her course of physical therapy and is scheduled to see her primary care provider for a recheck. The physical therapist has sent a report describing Luisa’s progress.
In this final event that we’ll look at the recheck intake, interview, physical exam, and plan of care for Mrs. Sanchez.
Primary Care Recheck – Interview
Recheck Intake
Luisa repeats the pain measures from the first visit to her primary care provider. Her current pain is 0 of 10, best 0 of 10 and worst 2 of 10.
Physical Therapy Final Report
Body Diagram
Please see the body diagram Luisa completed at the time of her recheck with her primary care providers. Note the reduction in surface area for Luisa’s drawing of her pain area.
Pain
Neck pain decreased from 8 of 10 to 2 of 10 on faces pain scale.
Motion
Active range of motion of neck and shoulders within normal limits (WNL).
Strength
Bilateral upper extremities 5 of 5 .
Neck Disability Index
Disability decreased from 68% to 12%.
Functional Activities
Able to resume activities of driving, church and family activities with minimal discomfort.
Home Exercise
Walking 20 minutes per day and independent with upper quarter exercise.
Full Report
Physical Therapy Treatment Documentation November 22nd
Subjective
Patient complaint of neck pain with use of Spanish faces pain scale for pain report.
Patient notes her pain is generally 0 to 2 on the faces scale. Pain in posterior neck.
Patient denies headache.
Objective
Treatment focus on therapeutic exercise, home exercise program, manual therapy.
Bilateral upper extremity ergometer level 5 x 6 minutes forward and backward.
Bilateral upper extremity strengthening with 6 pounds, 4 pounds, 2 pounds for shoulder flexion, extension, external rotation, abduction x 10 repetitions. Ball throw with 4 pounds x 2 minutes. Overhead ball throw at wall x 10 minutes. Clockwise and counter clockwise ball roll at wall at 90- and 120 –degrees x 2 minutes each.
Assessment
Patient independent with home exercise program. Patient progressing with increased endurance in bilateral upper extremity and cervical regions. Patient with reduction in pain, increased activity. AROM of cervical and bilateral upper extremity WNL. Strength of BUE and neck 5- of 5 bilaterally. Neck Disability Index repeated with decrease from 68% to 12 % disability demonstrating improvement in function and reduction in pain interference in activities and functional postures. Patient independent in her home exercise program. All goals have been met and recommend discontinuance of home exercise program.
Plan
Discontinue physical therapy at this time.
Primary Care Provider Recheck Final Visit Plan of Care
Based on her interview and examination, the primary care provider makes the following recommendations for Luisa.
- Continue with independent exercise and activity
- Return dosage of acetaminophen to as needed
- Recheck in 3 months
Wrap Up
Patient Centered Goals
Decreased Pain
Goal met. Luisa's pain decreased from 6 to 2 on a 0-10 scale.
Improved Mobility
Goal met. Luisa is able to turn her head and look down.
Driving as Needed
Goal met. Luisa is able to drive her grandkids to school; drive as needed for church and social activities.
Caretaking With Grandkids
Goal met. Luisa is able to play with her grandkids and take them to/from school.
Community of Faith
Goal met. Luisa has been able to return to church and resume her activities.
Sleeping Without Pain
Goal partially met. Luisa has some discomfort upon waking but able to sleep without waking up.
Weekly Bowling
Goal met. Luisa returned to her weekly bowling league
Take Home Messages for Hispanic Older Adult with Acute Neck Pain
So, what do you think the take home messages for this case scenario? There are at least four of them.
- Non-pharmacological strategies can be a first line treatment strategy for acute neck pain.
- Language and culture are important components of treatment of acute pain in older Hispanic adults.
- Acute pain education should include strategies to address risk factors for chronic pain.
- Medical interpreters play an important role in decreasing language barriers during patient and provider interaction.
Can you think of more?
Congratulations
Congratulations! You have completed Luisa Sanchez: Hispanic Older Adult with Acute Neck Pain module.
