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Patient by Mind Map: Patient

1. medication

1.1. takes baclofen as needed for spasticity

1.2. occasional use of NSAIDs

2. social history

2.1. wife and 4 children

2.2. reports great support system

2.3. in school to become a social worker

2.4. occasionally drinks on weekends 4-7 drinks

2.5. reports that he has his injury has taught him to appreciate his life more, reports no issues with depression or anxiety

3. environmental

3.1. socioeconomic status limited his ability to get the assisted devices that he needed

3.2. 4 steps to enter home with railings

3.3. Has friends that live on 2nd floor of apartment complex that he regularly ambulates

4. PMH

4.1. 28 yo male

4.2. no history of systemic disease

4.3. s/p T4 Asia D SCI 2 years ago

5. activity limitations

5.1. sitting balance

5.1.1. LOB when reaching outside BOS

5.2. standing balance

5.2.1. increase postural sway during rhomberg stance

5.3. gait

5.3.1. decreased foot clearance

5.4. stairs

6. impairments

6.1. decreased sensation in L LE

6.2. L LE and abdominal MMT grossly 3 + / 5,

6.3. increased tone

6.3.1. DF and knee extension

6.3.2. increased clonus with DF

6.4. increased synergy and spasticity

6.5. static sitting and standing balance

6.5.1. decreased ankle strategy

6.5.2. SLS <10 seconds with BUE support

6.6. decreased endurance

6.7. posture- forward head and kyphosis

7. lifestyle

7.1. very active PLOF

7.2. he is starting a start a support group to help those with lower socioeconomic status get access to the devices and help that they need

7.3. goes to the gym 5 days a week, and OP 2x a week

7.4. tries to walk 2x a week on treadmill with BUE support and knee brace

8. level of assist

8.1. required CG for sit-stand

8.2. requires Min A during gait

8.3. independent for bed mobility, grooming, and dressing

8.4. requires min-mod assist ambulating stairs in order to prevent knee buckling

9. Assistive Devices

9.1. uses WC for ambulation in the community

9.2. uses losartan crutches for ambulation in the home and short distances <200 ft

9.3. use of L knee brace to prevent hyper-extension of the knee during gait

9.4. uses shower chair as needed

9.5. uses catheter to void

9.6. uses braces for the ankles to prevent PF contracture and increase foot clearance during gait

10. PT intervention

10.1. strength and ROM

10.2. prevention of ulcers

10.3. WC training

10.3.1. wheelies

10.3.2. ramps/curbs

10.3.3. transfers

10.3.4. parts management

10.4. gait, balance, and stair training

10.5. decrease pain and spasticity/tone

10.6. endurance training

10.7. walkaide/zero G

10.8. YOGA