Clinical Practicum 1

Clinical Reasoning

Orthopedic Retrospective Case Analysis

This is designed to assist you to develop clinical reasoning skills and evaluate your decision making with an orthopedic patient. Please fill out each section AFTER the listed treatment session.

  • This form is to be completed on a patient that you have seen/observed the initial evaluation and throughout several treatments, hopefully to DC.
  • This can be the same patient as in the Planning the evaluation and treatment form.
  • This will be presented to the class and faculty when you return in a short 10-15 minute presentation.
  • The presentation should demonstrate your continual assessment and reassessment as well as your clinical reasoning for this patient. How you adapted to a changing presentation or how you were able to prove your initial hypothesis.
  • Also include in your presentation an overview of the treatment that the patient received and the patient’s response to your interventions.
  • The Retrospective Case Study is a review of YOUR care of a patient and should demonstrate your integration of the coursework you have had in the Physical Therapy Program at MUSC. It is not a review of your CI’s treatment approaches.
  • The Retrospective Case Study is to be based on the current best evidence. It should include one slide with a review of an article that supports your course of treatment with the patient. The article should be referenced in the footer in AMA style.

INITIAL EVALUATION

  1. After your initial evaluation, state your primary and secondary hypotheses.
  1. Primary hypothesis (diagnosis):
  1. Secondary hypothesis (diagnosis):

Supporting History dataInitial *

/

Supporting Examination dataInitial *

AFTER the THIRD VISIT

  1. Restate your primary and secondary hypothesis:
  2. Primary hypothesis (diagnosis):
  1. Secondary hypothesis (diagnosis):
  1. Identify your prognosis for this patient:
  2. Favorable:
  1. Unfavorable:
  1. Identify your subjective and objective asterisks at the end of Day 3 and how EACH asterisk has changed since Day 1. Did the asterisks change consistently as you treated the patient? If an asterisk did not change, what additional examination and/or treatment could you have done?

Current Status of Subjective *

/ Current Status of Objective *

AFTER the FOURTH VISIT

  1. PrimaryHypothesis (diagnosis):
  1. Prognosis:
  1. How has your understanding of the patient’s problem changed from your interpretations made following the first treatment? (If yes, how?)
  1. Has your prognosis for the patient changed from your initial eval? If yes, what factors led to a change in prognosis? (e.g patient’s motivation, other health related problems)
  1. On reflection, what clues (if any) can you now recognize that you initially missed, misinterpreted, under- or over-weighted?

AFTER DISCHARGE (5-6 visits)

(If Possible)

  1. How has your understanding of the patient’s problem changed from your interpretations made following the third treatment?
  1. In hindsight, what were the principal source(s) and mechanisms of the patient’s symptoms?
  1. Mechanisms of injury:
  1. Sources of symptoms:

***Your presentation should also include an overview

YOUR care of the patient. ***