Case Report Projects - 2009/2010 Academic Years PT 576 Synthesis of Clinical Evaluation and Intervention PT 587 Clinical Internship PT 588 Clinical Internship PT 676 Clinical Mastery For each internship (PT 587 and PT 588), you will select one case and collect appropriate information to subsequently complete a case report. The case you select in each affiliation must reflect an example where YOU made a significant contribution to the initial examination, evaluation, goal setting, and subsequent intervention delivery. It is not appropriate to use a case where you did not participate in all of the above areas – for example clinical instructor (CI) completed examination/evaluation without your participation. The selected case must also allow you to exhibit effective delivery of physical therapy services and clinical decision making. It will be necessary for you to arrange with your Clinical Instructor your active participation in the examination/evaluation of a client and subsequent delivery of therapeutic interventions. This will likely have to occur during the middle portion of your summer internship (week 3) and during the second week of your winter internship. PT 587 To assess your success at collecting the appropriate information to complete the case report you will be expected to submit a case title, five page summary narrative of your case, and a reference list (including 10- 15 references from the primary literature - “research articles”; not included in 5 page limit) for your selected case. Be sure to cite (author, year) your references where appropriate within the text of your narrative and briefly describe how the reference finding relate to your case. While evaluating and treating your selected patient, you will be expected to have investigated the literature concerning pertinent issues related to the case (evidence based practice). This would include review of primary literature related to the pathology (physical stress model, healing rate of tissues involved), pharmacology, kinesiology, clinical medicine, and interventions as well as primary literature supporting the clinical management of your client (validity and reliability of tests and measures, intervention selection, intervention intensity, intervention progression). These resources will be contained in the reference list you submit with the case summary. The case summary narrative is to be 5 pages in length (excluding title page, references and appendix), 1.5 line spacing, 12-point font, and 1-inch margins. Tables of examination results or lists may be single spaced. If space is an issue you can place your tables in an appendix at the end of the paper but be sure to identify each table in the narrative (See Table X in Appendix). During the preparation of your case report you may wish to construct a “consistency table” to assure that your report exhibits the necessary consistency in clinical decision making. Be sure to maintain confidentiality in your paper. Never refer to your client, clinical instructor, facility, or others you interacted with by name. Locations can be identified in no greater detail than the state – outpatient clinic in Montana, hospital in Montana, etc. Examples of case reports completed in the past are available for your review in the PT 576587 Folder in the 2nd floor learning center. This document should summarize the major aspects of the case including: Title page: Title Student’s name Reviewer’s name (to be completed fall semester by a third year student) Date Narrative: I. Practice environment of Internship (Outpatient, Acute Care, etc): II. Referral situation and statement. (ex. self referred for back pain; or referred by orthopedic surgeon for evaluation and treatment post ACL reconstruction, etc.) III. Patient Examination (include date of initial visit) – note this includes the initial examination as well as any re-examinations done later. A. Patient/Client History B. Systems Review (General Screens, Observations) Cardiovascular/Pulmonary, Integumentary, Neuromuscular, Musculoskeletal C. Tests and Measures - research literature support of reliability, validity, etc would be appropriate. IV. Summary information related to pertinent anatomy, physiology, kinesiology, clinical medicine, pharmacology concerns. Include references. This information should be integrated into the other parts of the narrative and not presented as a separate section. V. Evaluation A. Significant Findings/Problem List - Categorize problems based on the ICF model - pathology, function and structure impairments, activity limitation, participation restriction, and the contextual factors - environment and personal. B. Assessment statement C. Diagnosis – Practice Pattern and related ICD-9 code D. Prognosis Prognosis statement and your rationale. Long-term goals (expected outcomes). 1. Long-term goals must be measurable, possess a time frame for accomplishment, and assess a functional task – SMART goals. Make sure goals address problems identified. 2. These goals should also address risk reduction, prevention (primary, secondary, tertiary), impact on societal resources, and client satisfaction. Short-term goals – are a subset of the long-term goals. These goals should also have a time frame, be measurable, and may assess an impairment or function. Plan of care. 1. Expected frequency and duration of treatment program. 2. List planned interventions related to: Coordination and Communication Patient/Client Instruction (Primary/Secondary Prevention) Direct Intervention This list should include the appropriate CPT codes for the selected interventions, if appropriate. 3. Include the anticipated discharge plan. State who is paying for the services provided and what the expected cost of this episode of physical therapy care will be. Include a brief statement how reimbursement issues influence the plan of care if applicable. VI. Actual Intervention: Briefly describe how the course of intervention proceeded. Especially note any deviation from the plan of care and the reason for the deviation. Include research literature to support your selection of interventions as well as intensity and progression. VII. Achievement of Outcomes: Briefly describe the status of the patient at discharge or discontinuation. (compare baseline objective measures with measures taken at d/c and referenced to goals) If your interaction in the case ceased before the end of the case, describe the pt’s status at that point in time and your assessment of what the outcome will be. VIII. Reflection: Please comment on the following: What would one do the same? What would one do differently? (address three issues that went well and three issues that needed improvement) When addressing areas of improvement provide specific changes you will make in the future and the rationale (literature support). What was the most challenging aspect of this case? What barriers had to be overcome to reach the outcomes? What strategies were used? Key “take home” messages. IX. References: It is expected you will have 10-15 references embodied into your case report. The great majority of the references should be from primary sources (research articles not texts or review articles). Use American Psychological Association Publication Manual format. The APA Style Manual (808.06615 P976 2001) is available at the Information desk of the Mansfield Library and in the Physical Therapy Program office. Examples: Periodical: Author, A.A., Author, B.B. & Author, C.C. (1994). Title of article. Title of Periodical, xx, xxx- xxx. (volume, pages) Non-periodical: Author, A.A. (1994). Title of work. Location: Publisher. Citation within text of paper: (Author & Author, 1994) or (Author et al., 1994) Please keep in mind the comment from William James, “The art of being wise is the art of knowing what to overlook.” Evaluation of the PT 587 Short Case Report 1. Turn paper into Dr. Fehrer on the first day of class, Monday August 31, 2009 (if you completed the internship during the first summer session) or Friday September 11, 2009 (if you completed the internship during the second summer session). 2. Paper given to 3rd year DPT student to critique. 3. 3rd year DPT student goes over the critiqued paper with the 2nd year student and provides recommendations for revision. 4. 2nd year student completes revisions and returns revised paper to 3 rd year DPT student. 5. When both the 2nd year student and the 3rd year DPT student are satisfied with the quality of the paper the final product will be submitted to Dr Fehrer for grading. 6. The resulting grade will be part of the course grade for PT 676 (Clinical Mastery) for the 2nd year student the following year. The third year student’s critique grade will be included in the PT 676 (Clinical Mastery) for the 3rd year DPT student. PT 588 Winter Clinical Internship and PT 576 Synthesis Case report + PICO/CAT When you return to campus Spring semester 2010 you will be enrolled in PT 576 “Synthesis Evaluation and Intervention” where you will prepare a formal detailed case report based on the case you selected during your winter clinical internship. You will complete a formal case report document under the guidance of an assigned faculty reviewer. During the first several sessions of PT 576 you will address the construction of the various parts of your 8 page case report narrative. Also during the first few weeks of the Spring semester, you will present a detailed outline of your case to your faculty reviewer and set up a 45 minute meeting to discuss your case report with your faculty reviewer. Your faculty reviewer is required to meet with you only once regarding this case report. In late March of early April, you will turn in the completed case report document to your faculty scholarly project advisor for grading. The formal case report document for PT 576 will reflect both the prospective and retrospective analysis of the case and extensive review of the primary literature supporting the various aspects of the case. This document is not to exceed 8 pages in length (excluding the title page, abstract, tables, figures, and references) and be double-spaced, 12-point font, and 1-inch margins. Examples of case reports completed in the past are available for your review in the PT 576587 Folder in the 2nd floor learning center. This document should contain the following content. I. Abstract – Half to one page summary of the major points presented in the case report. II. Introduction – Practice environment in which you interacted with the client (acute care, outpatient, etc.), medical diagnosis, physician order, and paragraph describing the chronology of the current medical event for the client. If your client had a complex series of interventions or received multiple episodes of care for this medical problem please include a table illustrating the chronology of the pertinent events. III. Patient Examination A. Patient/Client History – date of initial visit, informed consent (describe how it was obtained and documented), general demographics, social history, employment, growth and development, living environment, general health status, social habits, family history, medical/surgical history, current condition, functional status, medications (show evidence of understanding the action of the medication and impact on PT intervention performance – both positive and negative, scientific literature support; did you observe any adverse effects during treatment, if so what did you do about it), other clinical test results, client goal for therapy. State the source of each of these pieces of information – chart review, patient interview (subjective report), client/caregiver/family member completed survey. B. Systems Review – general screens. This information can be presented as tables/outlines with explanatory descriptors. 1. Anatomical and physiological status of cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems. 2. Communication ability, affect, cognition, language, learning style, consciousness, orientation. C. Tests and measures actually conducted by the physical therapist during the examination process and the result(s). Present this information as tables/outlines with explanatory descriptors. Note that the examination is not limited to just what was done during the first visit, but includes all the examinations completed throughout the therapy program. Provide/discuss literature evidence for rationale for test/measure selection – validity, reliability, evidence-based practice. IV. Evaluation – clinical judgments. A. Problem List – categorize the problems observed during the examination based on the ICF model - pathology, function and structural impairments, activity limitation, participation restriction, and the contextual factors - environment and personal. Also consider in this section the severity and complexity of impairments, probability of prolonged impairments, and potential discharge destinations. B. Assessment statement – synthesizing the results of your exam, the conclusions you have made based on the medical diagnosis, interview, observations, and results of the exam(s). This is NOT a summary of your examination results. C. Need for referral to other members of the health care team or community resources – explain how these referrals were accomplished. V. Diagnosis A. Preferred physical therapy practice pattern B. ICD-9-CM code VI. Prognosis A. Prognosis statement and your rationale for this prognosis decision B. Long-term goals (expected outcomes) 1. Long-term goals (SMART) must be measurable, possess a time frame for accomplishment, and assess a functional task or disability. 2. These goals should also address risk reduction, prevention (primary, secondary, tertiary), impact on societal resources, and client satisfaction. C. Short-term goals – subset of the long-term goals. These goals (SMART) should also have a time frame, be measurable, and may assess an impairment or function. D. Plan of care. Expected frequency and duration of treatment program. List of therapeutic activities to be utilized for the rehabilitation of this client. This list should include appropriate CPT codes for the selected interventions. Include the anticipated discharge plan. E. State who is paying for the services provided and what the expected cost of this episode of physical therapy care will be. Also address what portion of the charge is being paid by a 3 rd party (insurance) and what portion is being paid by the client (deductible). VII. Intervention – this section describes the therapeutic interventions actually provided to the client. A. Coordination, communication, and documentation – these may be summarized together as an integrated paragraph if appropriate. B. Patient/client-related instruction. C. Procedural interventions. 1. Provide table or list of specific interventions provided to the client. This should include examples of content of “typical” treatment sessions and home exercise programs, and illustrate the progression of the treatment program. This can be a general summary with a more specific description of key or uncommon interventions. 2. This section should include a description and rationale for the therapeutic interventions considering number of replicates, number of sets, criteria for progression of intervention, and application descriptors for modalities. This support should include discussion of the scientific literature – evidence based practice. 3. Describe any significant deviations from the original plan of care. Also provide an explanation for the imposition of the deviation from the plan of care. VIII. Achievement of Outcomes – criteria for termination of physical therapy services. A. Reason for discharge or discontinuation of physical therapy service. B. Summary of goals achieved and reason(s) for goals not being achieved. IX. Reflections on the current case. A. What aspects of the case did you find effective and beneficial to the rehabilitation of your client? Address at least 3 aspects. B. What aspects of the case would you do differently in a future situation? Be specific as to the changes you would make, providing examples and primary literature support for your proposed changes. Address at least 3 aspects. C. Explain your decision making process in this case. Discuss alternative explanations for the changes observed. D. What barriers had to be overcome to reach the outcome? What strategies were used? E. Suggest future research questions – Where was the literature vague, or insufficient? F. Key “take home” messages. X. References in American Psychological Association Publication Manual format. You will be expected to have investigated the primary literature concerning pertinent issues related to the case report (Evidence based practice) and included this information in your report document. This investigation should occur while you are actually treating the client. XI. Consistency Table Comments on Case Report: 1. During the preparation of your case report you may wish to construct a “consistency table” to assure that your report exhibits the necessary consistency in clinical decision making. An important aspect of a quality case report is the consistency between the various components of the patient management scheme – examination, problem list, goals (short-term goals are a subset of the long-term goals), interventions. This can be exhibited through the completion of a table. The table can be started with any of the categories but ideally should begin with the examination. An example of a portion of such a table is provided below. EXAMINATION AROM R shld flex 0-90 PROM R shld abd 0-100 limited by pain 5/10 PROBLEM LIST Reduced R shld ROM Pain with overhead activity GOALS LTG - Pt able to complete overhead tasks pain free in 4 weeks STG- PT able to exhibit pain free AROM of R shld to 100 in 1 week INTERVENTIONS R shld grade III joint mobilization Cane assisted shld exercises Door pulley exercises PNF contract relax exercises HEP including hand walking up wall overhead Ice massage of R shld after exercises All interventions provided must reflect back to a goal, all goals should reflect a problem included in the problem list, and all problems must reflect data collected during the examination. Thus any portion of a case should be able to be traced to the other portions of the case. No intervention should be provided if it does not reflect a particular goal, part of problem list, and data collected during the examination. 2. In addressing the literature (evidence based practice), it is NOT adequate to just cite references in the text of your case report. You MUST briefly discuss the content of the reference material and its relevance to your specific case. Format for PICO/CATs Paper Based on your case study above, you will create a PICO question (foreground question) that asks for specific knowledge about managing the patient described in the above case study. You will then complete a review of a primary literature article (not a meta-analysis or review) in the format of a CAT. The PICO/CAT will include the following: CAT – Critically Appraised Topic – See examples in LSS red binder in SB 129. Title Clinical bottom line statement Citation – author, title, journal citation PICO question P – patient and/or problem I – intervention C – comparison intervention O – clinical outcome Search terms and data bases used Study Features – randomly controlled trial (yes/no), blinding, intention to treat, was the randomization list concealed Patients key clinical characteristics Control regimens and durations Experimental regimens and durations Evidence – evaluation of the major outcomes of the study and the statistical support, appropriateness of statistical analysis Comments: Were all the subjects analyzed in the groups to which they were randomized? Were the subjects and clinicians kept blind to the interventions? Were the groups treated equally, apart from the experimental treatment? Were the groups similar at the start of the trial? Are the results of this therapeutic trial valid? Was the follow-up of the patients sufficiently long and complete? Are the statistical differences presented of clinical relevance? Are the valid results of this trial important? Are the valid and important results applicable to your specific patient? The likelihood of help versus harm Date of Birth of CAT Kill or update by ________ CAT author – name, address, email The PICO/CAT is single spaced and should not exceed 2 pages in length.