Patient Name: Larsen, Millie
Reason For This Admission: Acute confusional episode, Dehydration, UTI, HTN
PMHx: HTN (2000); Hypercholesterolemia (2015); Glaucoma (2005); Postmenopausal
(1975); OA bilateral knees; Stress urinary incontinence (2014)
PHYSICAL THERAPY INITIAL EVALUATION, Day 2 of Hospital Stay
S: When asked if patient has fallen in the past year, patient responded after much
prompting “I might have fallen once or twice.” Patient also reports pain in both knees if
she walks a lot.
O: History: Patient was admitted to the hospital via ED after her daughter found her to
be very confused, including not remembering her daughter’s name. Lab work was
positive for mild dehydration and UTI. Daughter is also concerned that the patient may
be falling at home.
Social: Patient lives alone in a single story home. Patient’s spouse of 68 years died last
year. Patient ambulates without an assistive device and is active in her church. Patient’s
hobbies include gardening and cooking. Patient drives a golf cart short distances
to/from grocery store. Patient has one pet (cat). Patient denies ever smoking, drinking
alcohol, or using illicit drugs.
Cognition: A & O x 4. Patient follows directions throughout session.
Sensation: Light touch sensation is intact bilateral UEs and Les.
Motor: AROM bilateral UE and LE: WNL. Strength: grossly 4-/5. Mild crepitus noted in
bilateral knees. No swelling noted.
Integumentary: Faded bruising noted on bilateral knees.
Balance: Patient completed Timed Up and Go Test in 22 seconds.
Mobility: Bed mobility: Independent. Sit to stand and stand to sit: Independent.
Ambulated 75 feet with a slow gait pattern and decreased base of support without the
use of an assistive device. No loss of balance when walking with increased time needed
for changing directions. Patient tolerated sitting in chair x 45 minutes before becoming
fatigued.
Other: A small amount of urine noted on bed chucks. When asked, patient reports she
has experienced loss of urine with coughing and laughing for the past year but has had
some incontinence episodes with urgency over the past week. Patient reports she
remembers having a strong urge to urinate while in bed but didn’t realize she had
leaked urine. Patient asked if there is anything she can do to stop leaking urine.
A: Major impairments and activity limitations include:
1.
2.
3.
4.
5.
Impaired balance.
Reduced gait speed
High risk for falls given past history of falls and TUG score of 22 seconds
Decreased endurance
Stress urinary incontinence x 1 year and more recent episodes of incontinence
not associated with stress, which may be due to UTI.
Goals:
1. Ambulate 150 feet with no rest breaks.
2. Ambulate 100 feet while frequently changing directions and negotiating
obstacles without loss of balance with or without assistive device (TBD).
3. Tolerate sitting in bedside chair for at least 1 hour.
4. Increased LE strength by 1/4 grade to 4/5 for increased use in ADLs.
5. Completed Timed Up and Go Test in 14 seconds.
P: Therapeutic exercise and gait training QD-BID x 2-3 days. Progress sitting tolerance
and distance walked. Gait training with focus on balance, especially with turns and
negotiating obstacles. Patient and family education on reducing fall risks in the home.
Will also assess whether patient would benefit from an assistive device. Discharge
planning to include possible home health to decrease fall risk at home. Patient may also
benefit from outpatient pelvic floor physical therapy to address urinary incontinence.
Marilyn Schwarz, PT, DPT
Progress Note, Day 3 of hospital stay
S: “I don’t want to use a cane or walker. I don’t fall that much and when I do, I always
catch myself and don’t get hurt.” Patient reports she has not had any urinary
incontinence episodes today.
O: Patient went from supine to sitting edge of bed independently. Patient educated on
stress urinary incontinence and how strengthening the pelvic floor muscles can improve
continence. Performed pelvic floor awareness exercises to help patient identify pelvic
floor muscles. Patient instructed to contract these muscles before coughing and
laughing (aka “The Knack”) to decrease leakage. Patient transitioned from sit to stand
independently. Patient shown how to use a largel base quad cane. Patient initially
reluctant to use cane; however once patient was told it may help her knees feel better,
patient agreed to try using the cane. Patient ambulated 175 feet without using an
assistive device and once using large base quad cane. No loss of balance noted either
time. Patient ambulated faster with cane. Patient performed seated lower extremity
strengthening exercises, including glut sets, quad sets, hip flexion, knee extension, and
ankle pumps, 10x/set, 1 set each. After treatment, patient tolerated sitting up in chair for
lunch x 60 minutes.
A: Patient did well with identifying pelvic floor muscles and contracting. Patient also
ambulates with a faster gait using a large base quad cane, though patient reports she
does not know whether she wants a cane for home.
P: Continue gait training, pelvic floor exercises, balance activities, and lower extremity
strengthening exercises QD-BID. Will reassess assistive device needs.
Marilyn Schwarz, PT, DPT
Progress Note, Day 4 of hospital stay (Discharge Day)
S: Patient reports performing The Knack helps her leak less urine with coughing.
Patient states she no longer leaks urine in bed, leakage now only happens with
coughing and laughing. At beginning of session patient reported she does not want a
cane to take home but by end of session patient agrees to using a large base quad
cane.
O: Patient went from supine to sitting edge of bed independently. Patient educated on
contracting the pelvic floor muscles slowly (hold 5 seconds) and quickly (hold 2
seconds) to strengthen the pelvic floor. Patient instructed to perform exercises while in
bed and when sitting up in chair 10x/set, 3x/day. Patient transitioned from sit to stand
independently. Gait training focused on higher level balance activities, including
stepping over small objects, turning corners quickly, and walking backwards. Patient
was unsteady and loss of balance x 1 with PT needed to prevent fall. Discussed fall risk
and what happens when people fracture their hip. Patient performed same balance
challenges with a large base quad cane and no loss of balance noted. Patient
completed Timed Up and Go Test in 16 seconds without an assistive device. After
treatment, patient tolerated sitting up in chair for lunch x 75 minutes.
A: Patient did well with identifying pelvic floor muscles and contracting. Patient would
benefit from using a large base quad cane. Patient was much steadier when ambulating
using the cane when her balance was challenged.
P: Recommend patient is discharged home with large base quad cane and home health
PT to assess the home environment and mitigate fall risks. Once patient is discharged
from home health physical therapy, if patient is still having urinary incontinence
episodes, recommend patient to see outpatient pelvic floor physical therapist to address
further treatment for urinary incontinence.
Marilyn Schwarz, PT, DPT