Case Scenarios for Patient Care Seminar I
Spring 2014
Class of 2016
1. BPV
2. Sever’s Disease
3. ORIF ankle
4. TKA
5. CABG
6. ITB syndrome
7. Infantile Torticollis
8. ACL recon
9. GBS
10. Rib Fractures
11. Idiopathic Toe Walking
PCS I Cases
Katherine Deines, Jan Harting
Melissa Randall, Leslie Schein, Amy McDevitt
Jennifer Hide, Carrie Lamb
Andy Kittelson, Danielle Sockolosky, Sharon Jordan
Kyle Ridgeway, Dan Malone, Hope Yasbin Engel
Bahar Shahidi, Stephanie Pascoe, Audrey Waldron
Meghan Bawn, Lisa Hymes
Justin Dudley, Lauren Hinrichs, Lara Canham
Rebekah Griffith, Mark Manago, Angie Bruflat
Guy Lev, Renee Peter, Tami Struessel
Rebecca Downey, Nicole Parker
Spring 2014
1
Case #1
Benign Positional Vertigo (BPV)
(previously called Benign Paroxysmal Positional Vertigo or BPPV)
Patient Name:
Suzie Calfass
Case history:
Suzie Calfass is being seen in an outpatient PT clinic. Suzie is a 25 year old female who was
involved in a minor car accident 4 weeks ago. She was hit from behind while sitting at a stop
light. Initially she had headaches and a stiff neck. She experiences vertigo (the room spins)
when she rolls over in bed to the right. When she does this she becomes nauseated and the
room spins. She tries to avoid rolling to her right or sleeping on her right side. Denies any
symptoms of diplopia, dysphagia, dysarthria or drop attacks.
Diagnostic information
No x-rays or other diagnostic tests were administered. Suzie has come into your outpatient
clinic by referral from a family practice physician.
Medications
Birth Control Pills, daily vitamin
Past Medical History
Suzie is an otherwise healthy, active 25 year old. She is involved in a volleyball league at
school, runs 3 miles 3 times per week, and walks her dog daily. She is single and lives in a
condo near the school.
Social History
Suzie is a graduate student in the PT curriculum. She continues with her classes and has
some difficulty in class unless she avoids bending over to pick up her books or moving her
head quickly. She normally volunteers with a hippotherapy program, but has been unable to
participate since the accident.
Vital Signs
Heart rate 66 bpm, Blood Pressure 110/82
Systems Review
Cardiopulmonary: does not need further review
Endocrine (Gastrointestinal): Needs monitoring
Genitourinary: does not need further review
Integumentary: does not need further review
Musculoskeletal: needs further review
Neurologic: does not need further review Needs further review.
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Objective:
Upper quarter screen reveals 2+ DTR’s, negative myotomal and sensory screening, and
AROM of the cervical spine does not cause any UE pain or dizziness.
PCS I Cases
Spring 2014
2
MMT:
MUSCLE
GROUP
/MOTION
Elbow Flexion
Elbow
Extension
Shld Flexion
Extension
Abduction
Adduction
Int Rotation
Ext Rotation
Lower
trapezius
Middle
trapezius
RIGHT SHOULDER
LEFT SHOUDER
Strength
5-/5
5/5
AROM
150
0
Strength
5-/5
5/5
AROM
150
0
5/5
5/5
5/5
5/5
5/5
4+/5
4/5
178
60
182
0
35
90
5/5
5/5
4/5
5/5
4/5
4+/5
4/5
180
65
175
0
40
85
4/5
4/5
Cervical Spine AROM measured with fluid
inclinometer
Flexion
46
Extension
52
Right lateral
38
flexion
Left lateral
40
flexion
Right rotation 68
Left rotation
70
Longus Colli endurance test (held chin tuck in supine without head contact on table, for up to
1 minute) 25 seconds.
Suzie has a positive Dix-Hallpike to the right. She has upbeating, torsional nystagmus
toward the downward ear.
Vertebral artery testing is negative
Palpation: Mildly increased tone with palpation in the upper trapezius and levator scapulae
Dizziness Handicap Inventory:
Functional subscale: 8/36
Emotional subscale: 4/28
Physical subscale: 18/30
Total Score: 30/100
PCS I Cases
Spring 2014
3
Case #2:
Sever’s disease
Patient Name:
Cal Davis
Case History:
It is early Spring, and Cal is an 11 year old boy referred by his family physician for bilateral
heel pain due to Sever’s Disease. Cal started complaining of heel pain during his fall soccer
season but essentially was able to cope until his winter/spring basketball and lacrosse
practices overlapped. Cal was unable to run during either practice, nor participate in the
running activities during physical education (PE 5 days per week). He reports that his heels
hurt worse at the end of practice and games, especially after he is done playing. “I feel like I
am having growing pains and the pressure from my gym shoes and cleats hurt my heels.”
“When can I play my sports without hurting?” Cal and his parents are frustrated and very
anxious to begin a rehabilitation program. They are concerned over the mention of a growth
plate issue and very curious if this will impact his growth.
Current Medical Status:
Medications: Has taken ibuprofen 400 mg twice per day over the past 2 weeks.
Diagnostic information: His family was told that x-rays indicated that the growth plate in the
heel/calcaneus was still open and was likely the source of pain. Radiologist report read as
“Possible widening of calcaneal apophysis with small fragmentation, correlate with history
and physical examination.”
Medical History: Has been healthy and active his whole life other than a Colle’s fracture after
falling out of a tree when he was 10 yo.
Social History: Cal is an extremely active 11 year old. He plays 3 sports: fall-soccer and
lacrosse; winter-basketball and lacrosse; spring-lacrosse; summer-lacrosse. He is very stoic
when it comes to his pain because he knows that pain means limiting his activity. In addition,
he is in physical education classes 5 days per week. His PE teachers are quite concerned
and have been in touch with the parents. Cal is concerned about his ability to play high
school sports.
Vitals:
HR: 80
BP: 118/79
Observation: reddened area around both Achilles insertions into the calcaneous
Systems Review
Musculoskeletal: Needs further review
Neurologic: Needs further review
Cardiopulmonary: No further assessment required
Integumentary: Needs further review
Physical Exam:
Posture: hyperextended knees bilaterally; supinated forefeet, inverted rearfoot
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Palpation: tender and warm around the insertions of both Achilles tendons
ROM: Significant limitations in passive range: 0-degrees of dorsiflexion on right and 5
degrees on the left, full active and passive inversion, eversion and plantarflexion of the ankles
bilaterally.
Muscle/tendon length:
Short Achilles bilaterally during standing small squat: heel unable to stay in contact
with the floor
Supine- hip flexion--knee extension length test for the hamstring: lacking 40 degrees of
knee extension on right and 35 degrees on left
Strength:
Hamstrings
Quadriceps
Posterior tibialis
Peroneals
Anterior tibialis
Gastrocnemious*
R
5
5
5
4+
4
5
L
5
5
5
4+
4
5
*=pain with testing
Function: Is unable to play sports or participate in PEdue to pain during and after this activity.
He reports pain at the end of a school day after walking from class to class.
Gait: walks with slight antalgia, limiting his push off and taking slightly shorter steps
Pain: Visual analogue
PCS I Cases
1-10; 10 after activity and 5 in the morning
Spring 2014
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Case # 3:
Ankle fracture (ORIF)
Patient Name:
Sharon Olson
1) Case history: Mrs. Olson received a referral for physical therapy from her orthopedic
surgeon which reads “ROM, strengthening, balance training-please note that bone
scan shows moderate osteopenia., WBAT” Patient is seen at 5 pm following her
workday at an outpatient practice using bilateral axillary crutches and minimally weight
bearing on her right leg.
a. Current Medical Status- removal of a below the knee cast yesterday from her
right ankle following fracture when she slipped on ice and rolled her ankle while
picking up the newspaper. She was to remain NWB while casted, but is able to
WBAT at this time. Fracture occurred 10 weeks ago and surgical ORIF was
performed immediately where hardware was placed in her tibia and fibula
b. Medications- Actonel once per day
c. Diagnostic info-The right distal tibial and fibular fractures are well healed by xray.
d. Subjective- subjective report that swelling improves in the morning and is worse
in the evening. She reports that her tolerance to standing is about 15 minutes,
walking 5 minutes and that she wakes 1-2 times per night. She is able to
perform her work duties that are primarily sitting but has difficulty walking
around in the office for filing, mail distribution, and making copies and is unable
to carry large files from office to office. She reports that her boss was very
accommodating initially but he seems to be getting irritated that she has not
been able to return to her full work duties. Pain: Numeric pain rating scale 1-10;
8 after activity and 3 in the morning
2) Past Medical History: negative except for the new diagnosis of osteopenia.
3) Vital Signs:
a. HR: 76 bpm
b. BP: 118/78
4) Social information- Mrs. Olson is a 52 year old divorced female legal secretary. She
lives alone in a one level condo.
5) Systems Review

Cardiovascular-needs further review

Pulmonary- intact, does not need further review

Integumentary- needs further review.

Musculoskeletal-needs further review

Neuromuscular-needs further review

Communication/Learning- intact, does not need further review
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Based on the findings of the history and systems review, the following additional
tests/measures were completed.
6) Additional findings
i. AROM –right 0 degrees DF (knee extended), 35 degrees PF, 15 degrees
inv, 5 degrees ever. Left 10 degrees DF (knee extended), 60 degrees
PF, 32 degrees inv, 22 degrees ever.
ii. Swelling increased by 2 cm on right by Figure 8 measurement.
iii. Strength
1. Hip extension, flexion, abduction, adduction, IR/ER 4/5 bilaterally
2. Knee extension and flexion 4/5 bilaterally
3. Ankle
a. Resistive testing of right ankle deferred. Able to actively
move right ankle within available range (range as described
above)
b. Left: 4/5 DF, PF, inversion, eversion.
iv. Observational- Slightly overweight, mesomorphic body type. Generalized
atrophy noted in RLE. Incision is well healed. Skin dry and flaking. Scar
mildly adhered along fibula, but not irritable.
v. Gait-needed cueing to bear weight through the involved extremity. With
cueing and axillary crutches, she demonstrated reduced right stance
time, mild right circumduction, genu recurvatum on right with weight
bearing during stance, but reports “less pain than I thought I would have”
as she walks.
PCS I Cases
Spring 2014
7
Case #4
Total Knee Arthroplasty
Patient Name:
Roger Trenton
Case history: Roger Trenton is a 75 year old male who underwent a right total knee
arthroplasty one week ago and was referred to your home health agency following a 5 day
stay at the local community hospital. (He spent 3 days on the acute care floor and 2 days on
the transitional care unit (Skilled Nursing Facility (SNF) equivalent) for rehabilitation). The
referral is for physical therapy: evaluate and treat in the home, after which he will continue
with out-patient physical therapy. You are seeing him for the first time in his home where he
has lived alone since his wife died 5 years ago.
During the interview, Mr. Trenton reports that he was diagnosed with osteoarthritis in both of
his knees 10 years ago. At that time he had x-rays taken with clear evidence of a narrowed
joint space from thinning cartilage and an osteophyte at the medial joint line on the right
tibia. Recent x-rays showed increased narrowing and an increased size of the osteophyte.
Around that same time, he reports he was having pain with weight bearing (8/10), making
walking difficult. Ambulation with a single point cane helped some but his walking tolerance
was decreasing due to such severe pain on the inside of his knee. Pain even at rest was
5/10. Due to an increased sense of instability, increased varus deformity of right knee and
increased mobility limitations, the physician recommended a total knee arthoplasty (TKA).
One week ago the surgeon performed a right TKA, through a medial parapatellar approach.
Medications:
Naproxyn
Low molecular weight heparin
Oxycodone
Beta Blocker
Past Medical History: Ten year history of osteoarthritis in both knees. History of high blood
pressure controlled with medication. Myocardial infarction 2 years ago with stent angioplasty.
Vitals:
HR: 82 bpm
BP: 120/84 (right arm in sitting)
RR: 16
Body temperature: 98.4° F (oral thermometer)
Subjective: Mr. Trenton reports being glad to be home. He has minimal pain in the right knee
since coming home. He does not like to take the pain medications. He prefers the ice and the
home Continuous Passive Motion (CPM) unit. He states that he has a high pain tolerance
and is ready to get up and begin moving. He is having difficulty lifting his right leg and
standing on his right leg. He reported that he understood all the post-operative instructions
and exercises. He was already measured at 75 degrees of knee flexion. He has been using
the front wheeled walker since the surgery. He states that he is eager to get rid of the walker.
He was also instructed in how to use axillary crutches prior to surgery, and has the single
point cane he used regularly prior to surgery.
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Social information: Mr. Trenton has been an active dairy farmer all of his life. Despite his
age, he remains very active, assisting his sons and grandsons with work on the farm. He is
optimistic about his recovery and is eager to get back to work.
Systems review:
 Communication /Learning: intact, does not need further review
 Musculoskeletal system: Needs further review
 Neuromuscular system: Needs further review
 Cardiovascular/pulmonary system: Needs further review
 Integumentary: Needs further review
Based on the findings of the history and systems review, the following additional
tests/measures were completed.

Findings:
1. Pain scale (0-10) 2/10 in right knee; 1/10 in left knee.
2. Observation: no drainage, no elevated surface temperature. Incision looks to
be healing well. Right knee is moderately edematous compared to the left.
Wears full length elastic stockings (TED hose).
3. MMT not performed on the right knee. Observation of muscle performance
indicates fair quadriceps setting. He is able to contract the muscle but unable to
sustain the contraction or achieve end range knee extension. Bilateral hip MMT
4/5 abduction, 4/5 flexion, 4/5 extension. Left LE MMT 4+/5 knee flexion and
extension.
4. Right knee: AROM 10° to 70°; PROM minus 5° to 75°. Left knee PROM and
AROM 0-130°.
5. Bed mobility: uses hand to assist moving R leg in and out of bed. Independent
with turning in bed. Minimal assistance needed in getting his right leg in and out
of the CPM machine.
6. Transfers: Independent with sit<>stand from bed and dining room chair.
Standby assistance for toilet and couch transfers due to lower surfaces.
7. Ambulates independently on level surfaces with a front wheeled walker with
approximately 50% weight bearing from visual observation. He reports son held
on to his belt the one time he went to basement stairs. “It’s awkward going
downstairs with the walker.”
8. Home exercise program: patient demonstrates home program as shown to him
in the SNF prior to discharge. He is performing ankle pumps, heel slides,
quadriceps muscle setting independently. Requires minimal assistance with
straight leg raises.
9. Self-care: currently limited in bathing and lower extremity dressing. He reports
particular difficulty with donning TED hose. Occupational Therapy is scheduled
to visit the day after the PT initial evaluation, so detailed assessment not
completed.

Home evaluation-Single level ranch style home, no stairs for entry or to reach
bedroom and bathroom. Several throw rugs present. Able to maneuver into bathroom
with walker. Stairs to basement, but he rarely needs to use them.
PCS I Cases
Spring 2014
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Case #5
Status Post Cardiac Bypass
Patient Name:
Carl Bishop
Case history: Mr. Bishop is 59 years old. He was diagnosed with high cholesterol and high
blood pressure 15 years ago. 6 years ago he underwent angioplasty with stenting, which
helped temporarily with his chest pain. Recently, he was referred by his primary care
physician(PCP) to a cardiologist because he was very easily fatigued, and had begun to
experience some angina again with exertion. He has been using nitroglycerin frequently, and
his PCP was concerned, especially because his father died of a heart attack at 52. . The
cardiologist ordered a new angiogram which showed 3 arteries in his heart that were mostly
blocked, and suggested a consult with a cardiovascular surgeon. The surgeon
recommended a bypass procedure. You are seeing him in the hospital one day after this
procedure, with a referral stating “PT evaluate and treat. Precautions: median sternotomy”.
Chart Review:
You review the chart and find that he is to be on 2L oxygen by nasal cannula.
Laboratory Values
Glucose
Potassium (K+)
Ca++
Hemoglobin
Hematocrit
188 mg/ dL
4.2 mEq/ L
9.7 mg/ dL
9.6 g/ dL
39%
Vital Signs (taken
one hours before
your visit by
nursing)
HR
BP
RR
SpO2
72
105/ 68
20
95%
After reviewing the chart and speaking briefly with the nurse, you decide he is ready for a PT
evaluation and enter his room. He is lying supine, awake, but groggy. No family/friends are
present. The information below (Subjective/Social Information through Height/Weigh) is a
composite from the chart and from talking to Mr. Bishop.
Subjective/Social Information: Mr. Bishop is single and lives alone in a split level home with
4 steps to enter, and steps to go to his bedroom, bathroom and kitchen. He has trouble
keeping up with all the things he needs to get done around the house, and he can’t really
afford to pay anyone else to do the work. Before the surgery he was having trouble working
as an electrician because of fatigue and occasionally from chest pain. Lifting
supplies/materials at work was particularly strenuous. He is an Electrician for the IBEW Local
68, and mostly works on new construction. Since work has been scarce lately, he often works
60-80 hours per week if he gets called to a job. He must drive to his jobs, and the job
requires lots of walking and carrying supplies weighing up to 50#, sometimes more. He often
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works in awkward spaces, including crawl spaces, and up on ladders. He has limited social
support, but his sister lives nearby. In the short-term she will be helping with groceries and
transportation on discharge.
Medical History: Coronary artery disease (CAD), Hypertension, Hypercholesteremia
Current Medications: Lipitor (statin), Propanolol (beta blocker), cardiazem (calcium channel)
and aspirin. Patient controlled analgesia (PCA)/ morphine
Weight 200#, Height 5’9”.
Systems Review:
Cognitive and communication: English speaker, communication is unimpaired
Integumentary system needs further review based on history/surgery.
Musculoskeletal system needs further review based on history and observation
Neuromuscular system needs further review based on history
Cardiopulmonary system needs further review based on history and observation
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Observation: Mr. Bishop is lying in his hospital bed with a oxygen nasal cannula when you
arrive. He is awake, but appears groggy. A PCA device is attached to IV pole and he has
button in hand. On further observation, you note a median sternotomy, and mediastinal chest
tube to 20 cm H2O suction. He has an IV in his right forearm, a LLE saphenous vein graft
incision, and foley catheter.
Pain: He reports pain in his chest and left lower leg. When asked to clarify, he reports pain
from the incision and procedure, not chest pain like he had with exertion before surgery.
AROM: All movements are full with the exceptions noted below:
Right
Left
Shoulder flexion
120
125
Shoulder abduction
130
135
Strength:
*mild discomfort
Hip flexion
Knee extension
Knee flexion
Dorsiflexion
Gross Plantarflexion
Right
4/5
4+/5
4/5
4+/5
4/5
Left
4/5
4+/5 *
4/5 *
4/5 *
4/5 *
Functional Activities:
Min assist for bed mobility (rolling & supine to sit). Supervision for
sit to stand transfers. Instructed to limit upper extremity use to comply with sternal
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(sternotomy) precautions. He requires increased time and tends to hold his breath with all
activities. Verbal cues for breathing sequence and sternal precautions during these tasks.
Cardiopulmonary System:
Heart rate
Rest (supine)
After moving
from supine to
sitting
Activity
(Ambulation)
74
78
Blood
Pressure
100/ 66
98/ 62
Respiratory
Rate
20
20
Pulse
Oximetry
95
93
86
110/70
24
95
Ambulation:
Able to ambulate with a 4 wheeled walker 50 feet with CGA. Vital sign response as noted in
table above. Gait observation: shortened step length and decreased stance time on LLE
due to pain.
Timed Up and Go: 10.4 seconds
PCS I Cases
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Case #6
Illio-tibial band syndrome
Patient Name:
Isabella Benson
Case history:
Isabella is a 21 y/o single female college student. 4 weeks ago she began to notice pain on
the outside of her right knee while biking. At the time, she was riding about 100 miles per
week as she began to train for a race. In the past, she has placed in the top 10 for her age
group in the amateur division of several races, and riding is her primary form of exercise.
She uses clip type pedals. She continued to train and the pain became progressively more
constant. She is now completely unable to ride more than 2 or so miles because near the
bottom of her stroke (on the way down and way up), she gets intense pain on the outside of
her knee. Standing up out of the saddle on hills seems to increase her pain. She reports an
occasional grinding sensation that seems to decrease if she changes her knee/foot position
while riding. Isabella reports frustration in that she doesn’t think she will be able to compete
in the race in 4 weeks. She is even starting to notice pain walking between classes as the
knee has become more irritated. She’s normally very active, but this injury is starting to
impact her ability to stay fit. She denies trauma of any sort.. She is currently taking
Ibuprofen 600 mg 3 times per day for pain. She went to the student health center where
she received a referral for physical therapy. No radiographs were taken.
Social history: Isabella lives in an apartment with 2 roommates. Her immediate and
extended family live in a neighboring state.
Previous Medical History: She is in good general health. She reports some previous right
knee pain when riding long miles 2 years ago and occasional shin splints on both sides if she
runs significant mileage. Because of this tendency, she’s given up running completely and
only bikes.
Vitals: BP 110/75, HR 65
Systems Review:
No cardiovascular- intact, does not need further review
Neuromuscular or integumentary systems are intact and do not require further review.
Musculoskeletal system requires additional review.
Communication/cognition: intact, does not need further review.
Anthropometric characteristics: Ms. Matthews is 5 feet, 5 inches, 120 pounds
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Pain: Pain is located laterally over the condyle of the right knee. On numeric pain rating
scale, patient reports:
 2/10 at rest
 4/10 with significantly walking around campus
 7/10 with riding her bike greater than 2 miles
Observation: Moderate genu varum with high longitudinal arches bilaterally
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Lower quarter screen: negative sensation testing, AROM of the lumbar spine does not
reproduce any of her symptoms, DTR’s are 2+ bilaterally.
Sahrmann dynamic posture assessment:
 Small knee bend: drifts medially to the great toe
 Hip flexor length test (Thomas test): Greater hip extension when the hip is allowed to
abduct
 Single leg stand/maximum pelvic drop: while standing on right, note an anterior pelvic
tilt and medial femoral rotation.
Palpation:
 Tenderness rated as 6/10 over the distal ITB as it crosses lateral femoral condyle
 Significant muscular/tendinous tension over the right ITB
Muscle testing:
Quadriceps
Hamstrings
Dorsiflexors as a group
Plantar flexors
Gluteus Medius
Gluteus Maximus
*mild discomfort lateral knee
Right
5/5*
5-/5*
4+/5
5/5
4/5
4+/5
Left
5/5
5/5
4+/5
5/5
4/5
5/5
Joint Mobility:
 Patello-femoral, knee, ankle mobility normal
 Hip mobility normal except for mild decreased anterior glide of the right hip.
Flexibility:
 Decreased length hamstrings (on right, mild lateral knee discomfort), quadriceps,
plantar flexors
Clinician Observation with movement:
 Walking, patient is noted to bear weight laterally on both feet.
Gross foot mobility assessment: rigid feet bilaterally with high longitudinal arch.
Noble compression test: positive on right
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Case # 7:
Patient Name:
Congenital Muscular Torticollis (CMT)
Angela Dixon
Case History: Angela Dixon is a 3 ½ month old baby girl. She has been diagnosed with
Congenital muscular torticollis. Her parents indicate that they hope physical therapy can help
Angela. They are concerned about how her head appears to tilt to the right side most of the
time. They are most anxious for a remedial program.
Previous Medical History: Angela was born after an uneventful full term pregnancy, and she
has continued to have an uneventful perinatal period and has been healthy. She breastfeeds
fairly well initially, but recently has been having difficulty. Her mother finds that both mother
and baby are more comfortable when Angela is on the right breast, and therefore she is
breastfed on that side more often. Recently, Angela has been spitting up frequently and her
mother is concerned that she might not be getting quite enough to eat. Since she has been
spitting up so frequently, her mother reports that keeping her neck skin folds clean is a
challenge, and you note some skin maceration in the area.
At this time, Angela has grown in a predictable pattern on the pediatric growth chart. She
continues to have a rather erratic sleep schedule with occasional bouts of irritability. Her
developmental milestones were screened by her Pediatric Nurse Practitioner who
administered the Denver II Developmental Screening Test. The overall interpretation of the
test was “Suspect,” as she had three caution items. The caution items were “hands
together,” “head up to 90º,” and “sit-head steady.” At her two month well-child visit, her
mother asked the pediatrician about the appearance of her head tilting to the right side. The
pediatrician referred them for x-rays, and a radiological work-up did not identify any
abnormalities in the cervical spine. The pediatrician then referred Angela to an orthopedic
surgeon, and he has since referred her to you for outpatient physical therapy. Her vitals
were reported as follows: HR: 104 bpm BP: 85/78
Social Information: Angela lives at home with her parents. Both parents work outside of the
home, and she has a childcare provider (nanny) who takes care of her at home every day.
The childcare provider speaks Spanish as her primary language, but she understands most
of what is spoken to her in English. Angela has no siblings.
Systems Review:
Integumentary: requires further review
Musculoskeletal: requires further review
Neuromuscular: needs further review
Cardiopulmonary: does not require further review
Gastrointestinal: requires monitoring
Cognition/Communication: needs further review
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Additional findings:
When placed in prone and in supported sitting, Angela demonstrated adequate voluntary
control to hold her head against gravity, without bobbing, and look at objects and people in
her visual field. However, her head stays tilted to the right (right ear to right shoulder) when
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in supine, when she lifted her head in prone, and when she was held out away from a
supporting surface or her mother’s shoulder. She also held her head with the chin rotated to
the left. When encouraged to track an object visually, she actively rotated her head
approximately 90º to the left, but only about 30º to the right.
Passive range of motion of cervical side bending/lateral flexion was approximately 70º to the
right, and approximately 30º to the left. Passive cervical rotation to the right was limited to
45º degrees, but 90º to the left. Range of motion measurements were determined by visual
estimation. There is a slight flattening of the occiput on the left side of her head. Palpation:
Angela did not show any signs or symptoms of pain with palpation in any neck musculature,
but a small nodule was noted in her right sternocleidomastoid muscle.
Observational: Although Angela exhibits limitations in active range of motion, she does not
appear to be in discomfort. She does show some resistance with passive movement of her
head to the end ranges of right cervical rotation and left cervical side bending. Angela’s
mother and father gently rock her as they do passive stretches with her neck to gain range of
motion.
Inspection of the skin folds reveal maceration, but nothing severe. You discuss how to keep
those clean with her mother.
PCS I Cases
Spring 2014
16
Case #8: ACL reconstruction
Patient Name:
Ashley Smith
History:
Ashley is a 42 year old female with a referral for “physical therapy post left ACL
reconstruction, FWB using crutches, evaluate and treat.” She injured her knee jumping out of
her Fedex delivery truck holding a large package, during a snowstorm. She hit a patch of ice
and fell to the ground, twisting her knee inward, at which point she felt a loud pop. One week
after the injury, she underwent an ACL reconstruction using an ipsilateral patellar autograft.
Today is 4 days after the surgery. She reports that her knee feels like a “toothache” and is
moderately swollen, especially if she forgets to elevate her leg. She is walking most of the
time with her crutches, but does walk around short distances within her home without them.
She rates her pain as 5/10 on average that goes up to 7/10 at worst on a 0-10 verbal pain
scale. When it gets over a 5/10, she takes Vicodin.
Social history: lives alone in a 2 level townhouse
Work: She has been a Courier for Fedex for 12 years, requiring lifting up to 70 pounds,
frequently walking quickly on uneven surfaces, in all weather. She is currently off work due to
her injury.
Medical history:
a. Exercise-induced asthma that seems worse in cold weather. Smokes 1 pack of
cigarettes daily
b. Medications-using Vicodin prn for pain, inhaler for asthma
c. Diagnostic info-Pre-operatively, MRI confirmed a complete rupture of her left
ACL. No other structures were involved.
d. Vitals: HR 80 bpm, BP 125/85, RR 18
e. Height 5’7”, Weight 145 #
Systems Review

Cardiovascular-Pulmonary-requires further review

Integumentary- requires further review

Musculoskeletal- requires further review

Neuromuscular- requires further review

Communication/Learning Ability-able to respond to questioning, no issues with
communication
Physical Examination Findings
Inspection: 3 intact scope holes, and midline patellar tendon incision left knee. No redness
or drainage. Quadriceps atrophy evident left knee.
MMT
Right
Left
Quadriceps
5/5
Deferred
(see below)
PCS I Cases
Spring 2014
17
Hamstrings
4/5
Deferred
Gastrocnemius 4/5
3/5
DF
5/5
4/5 with mild
knee pain
Hip abduction
5/5
4/5 with mild
knee pain
Functional movement: unable to complete a quadset, or straight leg raise on the left.
Bed Mobility/Transfers: Is independent with all transfers, but tends to use arms to support
under knee during bed mobility and supine to sit and sit to supine transfers.
Gait: Tends to stand in genu recurvatum on the left and bears weight in standing only
through the toes of her left foot. She bears minimal weight on her left leg during gait, but
uses an appropriate gait pattern. Gait is cautious and slow.
AROM of her knee is -15-90 degrees with discomfort reported with overpressure into flexion.
Circumference measurements:
Right
Left
10 cm above
mid-patella
26 cm
24.8 cm
Mid-patella
27 cm
28.4 cm
10 cm below
mid-patella
24 cm
24.5
cm
Left positive ballotable patella. No joint line tenderness.
PCS I Cases
Spring 2014
18
Case #9:
Guillain-Barré Syndrome (GBS)
Patient Name: Gary Barnes
Case history:
Gary is a 30-year-old male who is employed as a sales representative for a computer storage
firm and reports that he was training for a marathon when his symptoms began. He
experienced a significant decline in function as a result of Guillain-Barré Syndrome, and has
been unable to work or exercise since shortly after his symptoms began. He has no
significant medical history. He lives in a 2 story townhome with his girlfriend. The bedrooms
and full bath are upstairs, with a half bath on the main level.
At the time of his first visit, he was an inpatient in an acute rehabilitation unit.
Initial visit:
He reported an initial onset of flulike symptoms during a vacation out of state. This was
followed one to two weeks later by the onset of severe myalgias and arthralgias in the legs
and unexplained fatigue. He was given a diagnosis of GBS one month after the initial onset of
symptoms, at which time he was unable to heel or toe walk, felt very fatigued, had
experienced a 15-lb weight loss, and was experiencing difficulty walking. After three weeks in
inpatient care where he received specific medical care but was not intubated, he was
admitted to the acute rehabilitation unit with stabilizing condition and improving function. At
the time of the initial interview, it had been 6 weeks since the initial onset of flulike symptoms.
During his stay in acute rehabilitation, he hoped to return to living independently with his
girlfriend and hopefully to return to walking. His ultimate goal was to return to exercising,
although he admitted doubts of being able to return to training as he had in the past.
At the time of the initial interview, Gary denied current fever, chills, or sweating, and his vital
signs were stable with BP 120/85 and HR 82 bpm. His skin color was normal. He reported
weakness and fatigue related to the GBS, and this at first limited his participation in therapy
to 20 minutes. In particular, he noted goals of improving moving around in bed, eating,
transfers, and walking and standing. . He did report feeling a bit depressed due to the
extremely unexpected turn his life had taken.
The Integumentary system: requires monitoring
Musculoskeletal system: requires more review
Neuromuscular system: requires more reviewe
Cardiopulmonary examination: requires monitoring
Psychosocial and cognitive systems: requires monitoring
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Deep Tendon Reflexes were absent for patellar tendon and Achilles tendon reflexes, 1+ for
bilateral biceps and brachioradialis and trace for bilateral triceps. Functional mobility was
more specifically assessed using the Functional Independence Measure (FIM). At initial
examination, the patient’s FIM score was 80/126, with a motor subscore of 45/91. FIM
subscores are noted in parentheses with each functional task observed. Observation
revealed that Gary required supervision and use of bed rails for bed mobility tasks of sit to
supine and supine to sit.(FIM score: 5) He required supervision to transfer from bed to
wheelchair when set up using a sliding board (FIM 5) He required minimal assistance without
the sliding board. (FIM 4) Gary required moderate assistance for bathing and dressing (3),
PCS I Cases
Spring 2014
19
minimal assistance for grooming and toileting, (4), and min assist for transfers to shower and
toilet(4). He was unable to ambulate but was able to propel a wheelchair 30 feet on level
terrain. (3)
Muscle performance was assessed using manual muscle testing (MMT) which revealed
significant symmetrical weakness as listed below. See below.
Sensory testing for light touch revealed that sensation was impaired in a glove-and-stocking
pattern.
MMT
Deltoids
Biceps
Triceps
Wrist
extensors
Wrist flexors
Hand
intrinsics
Hip flexors
Quadriceps
Hamstrings
Dorsiflexors
Plantarflexors
PCS I Cases
Right
3/5
3/5
2/5
3/5
Left
3/5
3/5
2-/5
3/5
3/5
3/5
3/5
3/5
3-/5
2/5
2-/5
1/5
2-/5
3-/5
2/5
1/5
1/5
2/5
Spring 2014
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Case #10 rib fx
Patient Name: Ahn Ngygen
History:
Ahn Nguyen presents to your outpatient clinic after her husband dropped her off for the
appointment. She is a right-handed 48 year old female who was involved in a motor vehicle
accident 8 weeks ago. During the accident, she sustained rib fractures in ribs 3-8 on the right
side and a punctured right lung, but was otherwise uninjured. She was an unrestrained
passenger in a car that was struck on the passenger side, and was taken to the ER and
hospitalized for 4 days. The chest tube was removed on Day 3, she was monitored for 24
hours, then discharged home using an incentive spirometer. She has had no specific issues
with her lungs since that time.
About 2 weeks ago, she tried to return to work, but was unsuccessful because she was in too
much pain with her work activities, including lifting, reaching and carrying cleaning supplies.
Not being able to work has become a major financial hardship for her family and her primary
goal for PT is to be able to go back to work. She works for a large contract cleaning
company cleaning offices in the evening. Specific requirements of the job include
lifting/carrying up to 50#, bending, reaching, stooping and lots of time on her feet. She is able
to perform her basic self-care activities, but reaching overhead to wash her hair, and reaching
behind her back are mildly difficult. She is getting used to using her left hand more, but that
still presents some challenges, especially with driving. She is normally very involved in taking
care of the house, and her family is assisting with most of that at this time.
Pain: Pain is located laterally over the rib wall, and is increased with movement like reaching
and bending, and with deep breathing. On the numeric pain rating scale (0-10), patient
reports:
 2/10 at rest
 4/10 with reaching overhead
 5/10 with lifting anything heavier than a plate of food at home
She denies any numbness or tingling, or pain in her arms or neck, but does report some
stiffness on the right side neck muscles.
Imaging: Xrays just before her failed return to work showed fully healed rib fractures.
Physician medical clearance: Her physician cleared her for return to work after the xrays
were read, but when return to work was unsuccessful, he referred her to Physical Therapy.
Medications: Taking 400 mg ibuprofen 3 times per day for pain control
Social history: Ms. Nguyen is of Vietnamese descent, immigrating to the United States at 18
yo with her parents and 3 sisters. She understands most spoken English, but has limited
reading and writing ability in English. Vietnamese is her first language, and it is spoken in her
home. She is married to her husband Hai Nguyen, and they have 3 sons 10, 13 and 16.
They live in northern Aurora, CO in a 3 bedroom ranch home.
Previous Medical History: Overall Ms. Nguyen is in good health, although she does not
currently do any sort of regular exercise. She does not smoke or drink alcohol.
Anthropometric characteristics: 5 feet, 2 inches, 110 pounds
BP is 112/90 and HR is 75 bpm
Systems Review:
Cardiovascular: pulmonary requires monitoring.
PCS I Cases
Spring 2014
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Neuromuscular: intact, does not require further review.
Integumentary system: requires further review
Musculoskeletal system: requires further review.
Cognition/Communication: requires monitoring
Other Systems: intact, does not need further review
Based on the findings of the history and systems review, the following additional
tests/measures were completed.
Observation: Slightly guarded, right arm held at side, with limited use of right hand for
reaching, and with limited arm swing
Posture: Rounded right shoulder, slightly guarded. Uses left hand for most reaching.
Upper quarter screen: negative sensation testing, AROM of the cervical spine does not
reproduce any of her symptoms although left sidebending is mildly restricted with pulling
through the right upper trapezius. DTR’s are 2+ bilaterally.
Sahrmann dynamic assessment:
 Standing shoulder flexion/elevation:
o ROM limited by pain on right and she tends to extend her lumbar spine to
obtain motion
o FMP: lacks scapular upward rotation

Pectoralis major length test:
o Right short clavicular and sternal portion
Palpation:
 Tenderness along entire right rib cage laterally, but no point tenderness.
 Closed scar from chest tube in the axilla, intercostals space between ribs 5 and 6
 Significant muscular tension right upper trapezius, infraspinatus, subscapularis
Thoracic spine AROM: limited by about 25% into right rotation, left rotation, and flexion with
reports of pulling and discomfort through the right ribs.
Shoulder complex AROM
Flexion
Extension
Abduction
ER at 90 degrees abd
IR at 90 degrees abd
*mild discomfort in ribs
Right
*155
55
*155
85
50
Left
170
60
170
88
65
Elbow AROM
Flexion
Extension
Right
150
0
Left
150
0
PCS I Cases
Spring 2014
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Muscle testing:
Infraspinatus
Supraspinatus
Lower trapezius
Rhomboids
Pectoralis major
Serratus anterior
Right
4/5*
4/5*
Unable to obtain position for
testing
4/5*
4/5*
Painful with any testing so
deferred
Left
5/5
5/5
4/5
5/5
4/5
4/5
*mild discomfort in ribs
Joint Mobility:
 Hypomobile ribs 2-9 right. Mildly hypomobile right glenohumeral joint all directions.
Hypomobile right scapulothoracic joint, with decreased upward rotation, elevation
Flexibility:
 Short latissimus dorsi and pectoralis major bilaterally, more severe on the right
 Mild pectoralis minor shortness
Clinician Observation of movement:
Protective positioning of right arm, and lacks normal right arm swing with gait
Reduced scapulothoracic motion with right arm elevation
Reversed scapulohumeral rhythm with right arm elevation
With deep inhalation and exhalation, rib expansion on right is decreased, and she
reports “tightness” and mild discomfort through the right ribs.
PCS I Cases
Spring 2014
23
Case #11 Idiopathic Toe Walking
Patient Name:
Collin Brown
Case History:
Collin is referred to your outpatient pediatric physical therapy clinic by his PCP with the
prescription reading “toe walking – ROM, strengthening, etc.” Collin is a 4-year-old male
with a diagnosis of idiopathic toe walking. His mother states this has been his walking pattern
since he began walking at approximately 14 months old. She was told he would outgrow this
pattern but this has not occurred. The toe walking seems to be getting worse with his recent
growth and he has difficulty with balance when he tries to walk flat-footed. Collin now
complains of mild foot pain at the end of his preschool day. His pain resolves with rest or after
a warm bath. From a communication standpoint, he is able to follow most instructions, talks
in 5-6 word sentences, and seems to understand the meaning of “hurt”
Social History He lives at home with his mother and step-father. He does not have trouble
getting around the home.
Past medical history: Collin was born prematurely at 32 weeks gestation. He was hospitalized
for 6 weeks in the NICU, but has been fairly healthy since home, except for frequent
respiratory illness, such as cold and coughs. Frequent upper respiratory infection. Heart
rate: 108 beats/min. Respiratory rate: 30 breaths/min.
Current Medical Status – Getting over croup
Diagnostic Information: A foot radiograph was taken at his 3 year old check up to
assess status/alignment of foot/ankle bones. No abnormalities were found.
Medications – None
Systems Review –
Cardiovascular -Pulmonary – requires monitoring
Integumentary – intact, does not require further review
Musculoskeletal – needs further review
Neuromuscular – needs further review
Communications/ Learning ability – requires monitoring
Based on the findings of the history and systems review, the following additional
tests/measures were completed:
Physical Examination Findings:
PROM – passive ankle dorsiflexion in subtalar neutral
Left
Right
o
Knee extended
-10
-5o
o
o
Knee flexed
-5
-5
Active ankle DF (knee flexed) -5°
-5°
Bilateral ankle plantarflexion is full. No evidence of clonus bilaterally.
PCS I Cases
Spring 2014
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Modified Ashworth scores are 1 for the hamstrings, quadriceps, peroneals, posterior
tibialis, toe flexors and gastrocnemius muscles.
Foot position in static standing – when heels are down, he stands with his knees in
mild hyperextension.
Pain: Collin Tolerates his mother rubbing his feet after a bath, but otherwise
hypersensitive. He appears most sensitive on his heels. He is able to point to a pain
scale picture that shows 4/10 pain when he comes home from preschool.
Movement and Gait: Collin is an independent community ambulator who does not use
any orthotics or assistive devices. When he walks, he demonstrates an increased
anterior tilt, increased lordosis with his arms often held up in a high guard position.
This posture is more pronounced with running. When walking backward, Collin’s ankle
dorsiflexion position does not change. When he is asked heel walk, he is able to get
his feet flat on the floor with increased knee hyperextension and he lifts his toes but
not his feet off the surface He uses his toe extensors to assist with active dorsiflexion
to clear his feet during swing phase of gait. Collin is able to balance at least 3
seconds on each foot. He does not yet hop on one foot or gallop, but he can jump
about 5 times in a row on both feet. His preschool teacher describes him as
hyperactive.
Resistive testing: (see chart) Not always cooperative, so +’s and –‘s may not be
completely accurate.
Muscles:
Iliopsoas / sartorius
Gluteus maximus
Gluteus medius
Adductors
Medial Hamstrings
Lateral Hamstrings
Quadriceps
Anterior Tibialis
Gastrocnemius / soleus
Peroneals
Posterior Tibialis
Toe extensors
Toe flexors
PCS I Cases
Left
strength
4
4+
3+
45
5
4
4
5
4
4
3+
5
Right
Strength
4+
4
4+
35
5
4
4
5
4
4
5
5
Spring 2014
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