Given a case....Given a case....

Name:T. E.72 /MaleDiagnosis: DM type 2 obese s/p

AKA (Dec 2008), HPN st. 2 good control s/p cataract surgery (2004)

Date of PTIE: March 16, 2009

What are the things that you What are the things that you need to know assess?need to know assess?

Chief complaint: “Di ako makalakad ng mag-isa”

HPI:- Underwent transfemoral

amputation of (L) LE d/t presence of arterial ulcers.

- Confined for a couple of days- Further subjective information to

follow...

Past Medical History:Cataract surgery (2004)HPN st II diagnosed since he was

18y.o.Diabetes since 1999Congestive heart failure 1970’sSmoking history: started 16y.o.

Stopped 1970’sAlcoholic beverage drinker

Family Medical History:Diabetes on both sidesHPN, siblingsPresent MedicationsSimvastatinTramadolMetoprolol

Personal / Social / Environmental- Retired electrician- Married with 2 children: 19 & 29- Accompanied in the house by

wife, children, and “pamangkin”- Likes to play chess and cards,

read newpaper, and answer puzzles

Lives on a two-level houseBedroom on the first levelBed approximately at the height

of his knees: located approximately 4m from the bathroom and 1m from the door of the house

Needs to negotiate a two-step stair upon entering the house

Most of the time, pt is on his wheelchair

Any pertinent information Any pertinent information that you might want to know that you might want to know about the patient....about the patient....

What tests and measures do What tests and measures do you need to perform?you need to perform?

OIW/c borne with caregiver

propelling the w/cPosterior skin flapTrophic skin changes on the (R)

anterior, lateral, and posterior tibial area

PalpationGrade 2 tenderness on the

posterior aspect of the stump

MMTSensory AxAnthropometryADL Analysis