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1. The patient is a 73-year-old man who presents with sudden onset of right knee pain, swelling, and fever. Medical workup included arthrocentesis, which revealed septic arthritis. Physical therapy evaluation showed decreased RLE strength, specifically right quadriceps, and decreased aerobic capacity as shown by sinus tachycardia and 14/20 RPE on Borg Scale during transfers. As a result of these physical findings and medical precautions of NWB, he required use of rolling walker and minimal assistance to complete all functional mobility. He would benefit from continued physical therapy to improve above deficits through ROM, strengthening, endurance, and functional training to maximize functional mobility and safety. Will continue to follow thrice a week and progress as tolerated.
2. Short-term goals:
Patient will perform supine to/from sit independently with HOB flat within 4 days to be independent at home.
Patient will be independent with home exercise program for BLE muscle strengthening and endurance within 4 days to optimize functional mobility.
3. Long-term goals:
Patient will ambulate 100 feet with rolling walker and supervision, demonstrating reciprocal gait pattern, within 7 days to be able to mobilize around home.
Patient will ascend/descend a flight of stairs + one rail with supervision within 7 days to get in and out of home.
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4. If the patient were to remain NWB on RLE at hospital discharge, the patient could demonstrate a hop-to pattern with LLE on the steps while placing bilateral hands on the single handrail. Assuming the patient is not ascending the flight of stairs multiple times a day, the patient’s wife could assist by placing the rolling walker on the second floor to use after successful stair negotiation. The patient and his wife could also have a chair set up for the patient to rest, since hopping on one leg is more metabolically demanding, especially considering physiological changes that occur with aging and hospitalization. |
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5. The patient’s rhythm strip reads a rate of 110 beats/min and a rhythm of sinus tachycardia. Explanations for this patient’s rate and rhythm include pain (10/10), anxiety (as reported by subjective), and/or in response to metabolic demand. |
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6. Two interventions to decrease the risk of developing a deep vein thrombosis are ankle pumps (in any position) or active mobility. Other interventions may include leg exercises, proper hydration, mechanism compression, and assessment regarding the need for referral to a physician. By having the patient perform active movements, facilitation of venous return is occurring. |
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7. Timeframe of periprosthetic infection is often divided into three categories: early, delayed, and late. Early is defined as infection that occurs within the first 3 months after implantation. Delayed is the period between 3 and 24 months, and late is more than 2 years after implantation. Patients are at greatest risk during the early timeframe.
8. Serum uric acid level and evaluation of arthrocentesis fluid for crystals evaluate the etiology of the presenting complaint. Gout and pseudogout present with similar symptoms to an acute septic arthritis, which include a painful, erythematous, hot, swollen joint. Gout results from an accumulation of monosodium urate crystals within a joint space. Gout is often diagnosed with elevated serum uric acid levels and negatively birefringent crystals in arthrocentesis fluid. Pseudogout results from the accumulation of calcium pyrophosphate dehydrate crystals within the joint space. Pseudogout will have positive birefringent crystals on arthrocentesis evaluation. Proper evaluation determines proper diagnosis, which guides appropriate treatment.
9. AM-PAC “6-clicks” is a functional assessment instrument used in the acute care setting. The AM-PAC measures three domains: basic mobility, daily activities, and applied cognition. Physical therapists use the basic mobility domain, which includes the following components: rolling, sitting down on and standing up from a chair, moving from lying on back to sitting on the side of the bed, moving to/from bed to chair, walking in the hospital room, and climbing three to five stairs with a railing. It is ranked on a 4-point scale with 1 being dependent and 4 being independent. The patient’s AM-PAC score is 18/24 because he scored a 3 on all functional components, which is based on his functional performance during his initial evaluation.
10. The body will respond to a stressful experience, such as a significant infectious process, by triggering several hormones in order to maintain energy stores. Blood glucose will be elevated due to elevations in counter-regulatory hormones. Increased secretion of catecholamines and glucagon initially raise glucose where increased secretion of cortisol and growth hormone leads to prolonged hyperglycemia in stress states. |
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11. The patient’s WBCs are elevated, which is also known as leukocytosis. The increase in WBCs is likely due to an infection, as found in the patient’s arthrocentesis performed on hospital day 1. The infection supports the patient’s clinical manifestations of fever and inflammation and pain at the knee joint. CRP is a protein made by the liver. It is an inflammatory biomarker. It is elevated as a result of the bacterial infection found in the patient’s arthrocentesis. |
