Case Report Template 2017
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Keywords[edit | edit source]
Word count[edit | edit source]
word count <2000 words
Author/s[edit | edit source]
Abstract[edit | edit source]
Introduction[edit | edit source]
Case Presentation[edit | edit source]
A 28 year-old caucasian female presents to the clinic with complaints of joint pain (arthralgia) and intermittent low back pain. Patient cannot recall any mechanism of injury. She reports she has trouble falling asleep at night and is unable to get a good nights rest. She often feels "restless" or "on edge", which she associates with not sleeping. She states she constantly worries about her performance in school, her family, and her mothers health, who has recently been diagnosed with Stage IV Small Cell Carcinoma. Patient also states she wakes up at night with throbbing headaches that last for a couple hours. She feels tense the majority of the day, causing her to feel stiff. She also has difficulty paying attention in class and finishing her homework.
- Subjective : Joint pain, low back pain, headache, muscle stiffness, difficulty sleeping and paying attention for approximately a year. Previously diagnosed with PTSD and treated with CBT.
- Demographic Information: Second Year Graduate Student, female, 28
- Medical diagnosis if applicable: Diagnosed with PTSD in February of 2000.
- Co-morbidities: Hypertension, drinks 10+ alcholic beverages per week (possible substance abuse), Depression
- Previous care or treatment: PTSD treated with Cognitive Behavioral Therapy by Clinical Psychologist following car crash in 2000.
- Self Report Outcome Measures: GAD-7 = 16/21, Penn State Worry Questionnaire (PSWQ) = 64/80, McGill Pain Questionairre = 42/78
- Physical Performance Measures: Oswestry Disablity Index (ODI) = 38%
- Objective : Vitals: HR= 98 bpm (tachycardia), BP: 146/92 mmHg (hypertension), RR= 24 bpm. Palpable muscle tightness in upper trapezius, forward flexed head along with increased kyphosis. Patient appears to be perfusely sweating and hands are cold and clamy to touch.
- Cervical AROM= limited extension and bilateral rotation
- Shoudler AROM= bilateral shoulder elevation decreased as well as shoulder flexion. All other shoulder AROM WFL.
- Myotomes= C1/C2, C2/C3 and C3/C4 weakness
- UE sensation intact
- LE AROM= limited trunk flexion/extension, along with knee flexion and ankle dorsiflexion deficits.
- Myotomes= L4/L5, L5/S1 weakness
- LE sensation intact
Clinical Impression[edit | edit source]
Summarization of examination findings, working diagnosis and targeted interventions
Intervention[edit | edit source]
- Phases of Interventions (e.g. protective phase, mobility phase, etc.)
- Dosage and Parameters
- Rationale for Progression
- Co-interventions if applicable (e.g. injection therapy, medications)
Outcomes[edit | edit source]
Findings Over time
Discussion[edit | edit source]
Summary Statement which should include related findings in the literature, potential impact on clinical practices
Acknowledgements[edit | edit source]
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References[edit | edit source]
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