Rhabdomyolysis Case Study

Author/s

Lindsay Matijevich, Katy Wiggins, Evan Scher, Kat Brock from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

100 word limit, non-structured description

Patient Characteristics

Patient is a 55 year old female that reports to your clinic with complaints of low back pain and leg pain. She is teacher at a local high school and reports that her back pain is making it difficult to sit for long periods. She complains of bilateral tenderness over her low back and generallized weakness of the lower extremities. She reports that she had the flu last week and she can't afford to miss anymore school so it's important that she get her pain resolved as quick as possible. She says that she still fatigued but attributes that to being sick and still not being fully recovered. She also mentioned during the evaluation that she felt extremely hot and clamy. Her temperature was taken and read 101. 3 degrees farenheight. When asked of any other symptoms she has noticed, she mentioned that her urine has been unusuallly dark the past week and almost looks bloody along with some mild shortness of breath that has been getting worse the past couple days. She again attritubed this to being sick and being dehydrated and deconditioned.

Patient has history of hypertension but has been able to control it with diet and exercise and has not taken medication for her high blood pressure in 5 years. Her father also has history of congestive heart failure and type 2 diabetes. She had her gallbladder removed 7 years ago but has otherwise had no other major surgeries. She takes no prescription medications regularly but has recently been taken over the counter aleve for her back and leg pain. 

• Demographic Information: (occupation/vocation, gender, age, etc.)
• Medical diagnosis if applicable
• Co-morbidities
• Previous care or treatment

Examination

• Subjective : Patient History and Systems Review (chief complaints, other relevant medical history, prior or current services related to the current episode, use relative dates i.e. years or months or days relative to onset of injury or start of treatment, patient/family goals)
• Self Report Outcome Measures
• Physical Performance Measures
• Objective : Physical Examination Tests and Measures

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• 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

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

Related Pages

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References

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