Physical Therapist Assistant Program

Patient History and Medications Assignment – PTA 2600 (50 points)

Note: The information to complete this homework assignment may be taken from the patient’s chart and/or patient with their consent during
the first or second week the patient is treated by the student.

Student’s Name: Jade Clawson

1. Age, Sex and Occupation (3 pts): 74, Female, none (previous paralegal).

2. Primary Diagnosis (2 pts): R BKA (below knee amputation)

DOI (Date of Injury): > 1 year DOO (Date of Onset): December 2018 (exact day unknown) DOS (Date of Surgery): 5-06-19

3. Past and present medical and surgical history (Include DOS for surgical procedures if available (10 pts):
PMH: Chronic R LE wound, OA, DVT, GERD, ankle fusion, R toe amputation, obesity, and hip fx, with multiple diagnoses and a complex medical hx.
Current/PMH: Admitted to hospital in December with R heel ulcer of > 1 year hx with MRI confirming osteomyelitis of R calcaneus and sepsis. A
R BKA was performed on 5-06-19.

4. Prior Functional Level (Total 10 pts):

a. Ambulation (i.e. independent, with FWW, with cane, with assistance x 1, etc.) (2 pts):
On level surfaces, (I)
b. Living situation (i.e. home, home with caregiver, senior living apartments, etc. (2 pts):
Prior: pt resided in private residence
After all tx: pt will return to live alone in private residence
c. Stairs and if so number of steps/where located (i.e. going into house, from main floor to bedroom, etc.) (2 pts):
Lived in single level private residence
d. Transfers (i.e. independent, assistance with caregiver, FWW etc.) (2 pts):
Prior: (I)
Present: (I)
e. ADL (i.e. independent, with assistance in dressing, etc.) (2 pts):
Before BKA, (Mod I) with dressing, toileting, & had shower aide 3x/wk, housekeeping 2x/mo, and Meals on Wheels.

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5. Medications: List at the medications the patient is currently taking and complete the information requested in the chart below (25 points).
Medication Indication(s)
1. Acidophilus/Pectin 1 capsule of 100 mg by mouth
capsule (lactobacillus) qd for GI prophylaxis (prevent
disease and balance GI
bacteria)
2. Esomeprazole 40 mg by mouth in the
Magnesium Capsule morning for GERD
3. Esomeprazole 40 mg by mouth in the
Magnesium Capsule afternoon for GERD
4. Fluvirin Suspension 0.5 ml intramuscularly PRN one
Prefilled Syringe time dose
(influenza vac type A&B surf
ant)
5. Gabapentin Capsule 300 mg by mouth qid for nerve
pain
6.Multivitamin/minerals 1 tablet by mouth in the
tablet morning for supplement
7. oxycodone HCI tablet 5 mg by mouth qid for pain
(Percocet)
Adverse side effects that could affect the patient’s physical therapy plan of care
and progress
Constipation, gas, bloating, increased thirst  Could affect pts desire to complete PT
and OT each day.
Headache, diarrhea, nausea gas, abdominal pain, constipation, dry mouth, drowsiness
 Could affect effectiveness of PT and OT as well as desire to participate in tx.
Headache, diarrhea, nausea gas, abdominal pain, constipation, dry mouth, drowsiness
 Could affect effectiveness of PT and OT as well as desire to participate in tx.
Soreness, redness, swelling, and bruising at the injection site as well as fever muscle
aches, headache or weakness  Could affect effectiveness of PT and OT as well as
desire to participate in tx. Could also affect how the pt completes upper body
exercises and WC propulsion until soreness from shot wears off in the arm.
Dizziness, drowsiness, unsteadiness, memory loss, lack of coordination, difficulty
speaking, viral infections, tremors, double vision, fever, unusual eye movements, jerky
movements, mood/behavior changes, depression, or anxiety  Could affect pt during
balance exercises, and fine motor control due to the many side effects. May also
impair communication with pt during tx. Pt may not feel safe during transfers.
Constipation, diarrhea, nausea, vomiting, heartburn, stomach pain, upset stomach,
black or dark-colored stool or urine, headache, unusual or unpleasant taste in your
mouth, temporary teeth stains  Could affect effectiveness of PT and OT as well as
desire to participate in tx.
Constipation, nausea, vomiting, upset stomach, sleepiness, drowsiness, dizziness,
lightheadedness, itching, headache, blurred vision, dry mouth, sweating, decreased
ability to feel pain, respiratory depression, apnea, respiratory arrest, circulatory
depression, hypotension, shock, death  Could affect effectiveness of PT and OT as
well as desire to participate in tx by making it difficult for pt to participate in balance,
coordination, fine motor, and aerobic conditioning exercises.
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8. pneumococcal Vac Inject 0.5 mg/ml Soreness, redness, swelling, pain, hard lump, warmth at the injection site, as well as
Polyvalent injectable intramuscularly as needed for muscle or joint aches or pain, fever, chills, headache, nausea, vomiting, weakness,
Prophylaxis PRN one time dose fatigue, skin rash  Could affect how the pt completes upper body exercises and WC
propulsion until soreness from shot wears off in the arm.

9. Tylenol 325 mg tablet 650 mg by mouth 4 hrs as Nausea, stomach pain, loss of appetite, itching, rash, headache, dark urine, clay
(acetaminophen) needed for pain colored stool, jaundice, dizziness  Could affect effectiveness of PT and OT as well as
desire to participate in tx due to the nausea or stomach pain. Pt may not feel safe
during transfers or balance exercises due to dizziness.

10. Xyzal tablet 5 mg 5 mg by mouth at bedtime for Headache, muscle aches, sleepiness, unusual drowsiness, sore throat, stuffy or runny
(levocetirizine allergies nose  Could affect effectiveness of PT and OT as well as desire to participate in tx.
dihydrochloride) The sore throat or stuffy/runny nose may affect pts aerobic conditioning during tx
and the muscle aches, sleepiness, and drowsiness could affect therapy productivity.

5/18/2019