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Given a case....

Given a case. Name:T. E. 72 /Male Diagnosis: 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 need to know assess?. Chief complaint: “Di ako makalakad ng mag-isa” HPI:

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Given a case....

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  1. Given a case....

  2. Name:T. E. 72 /Male Diagnosis: 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

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

  4. 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...

  5. Past Medical History: Cataract surgery (2004) HPN st II diagnosed since he was 18y.o. Diabetes since 1999 Congestive heart failure 1970’s Smoking history: started 16y.o. Stopped 1970’s Alcoholic beverage drinker

  6. Family Medical History: Diabetes on both sides HPN, siblings • Present Medications Simvastatin Tramadol Metoprolol

  7. 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

  8. Lives on a two-level house • Bedroom on the first level • Bed 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

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

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

  11. OI W/c borne with caregiver propelling the w/c Posterior skin flap Trophic skin changes on the (R) anterior, lateral, and posterior tibial area

  12. Palpation Grade 2 tenderness on the posterior aspect of the stump

  13. MMT • Sensory Ax • Anthropometry • ADL Analysis

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