Progress Notes - Clinical Notes
Social Worker Lindsay E at 07/16/21 0900 ALS MDC - Social Work Assessment / Interview The information below is from both a thorough chart review as well as an interview with Russ in ALS MDC today. Others involved in visit: Kristy Sharp from ALSA HCPOA: on file, no changes Verb Comm: requesting one be signed for son Matthew Preferred method of communication: Russ is non-verbal. He can communicate via MyChart, email, text. Insurance coverage: Medicare, United Healthcare secondary ALSA enrollment: yes Additional supports/services: none at current Patient/Family Current Status: Russ is a retired executive for a publishing company. He is divorced with one son who lives in Nashville. Russ splits his time between Madison (where he lived until 21) and Texas. He is an avid traveler, rides motorcycles, authors a blog, and has many good friends. Russ is a really delightful, funny, and interesting person. Patient/Family strengths: positive outlook, living in the moment, maintaining friendships Future planning, goals: continue to document his adventures, travel Any Barriers to getting needs met: extremely frustrated that he's had so many barriers getting IR see him for a tube change. He is open to learning how to change his tube himself. Next Step(s): notifying IR RN that Russ wishes to learn how to change his own tube (sent via Inbasket) Intervention(s): Offered my direct contact information and invitation to contact me with any needs. Submitted by: Lindsay N Everly, MSSW - 7/16/2021 - 1:11 PMProgress Notes - Clinical Notes Physical Therapist Laura G at 07/16/21 0830 UW Health - Physical Therapy Initial Evaluation Referring Provider: Dr. Andrew Waclawik Diagnosis: Bulbar ALS Onset date: 7/16/2021 This date represents the date of referral to the clinic Start of care date: 7/16/2021 1156 - 1222 Precautions: feeding tube, be mindful Assessment Clinical impression: The patient presents to the ALS clinic today with completely independence with gross functional mobility. We mutually agreed that he is not in need of additional PT at this time. Russell would benefit from regular follow ups from PT at ALS clinic to assess changes in condition and to provide continued education and recommendations. Relevant Medical History (medical history, medications, co-morbidities): Bulbar ALS Personal factors and environmental factors that may impact episode of care: none Presentation: Characteristics of the clinical presentation are evolving and/or has changing characteristics (moderate) PLAN OF CARE The plan of care and recommendations were discussed with the Patient. Russell and this therapist jointly agree that further physical therapy is not indicated at this time. I appreciate being involved in Russell's care. Mr. Newton was encouraged to contact me via MyChart or telephone with any questions or concerns that arise regarding the above assessment or plan of care. Informed Consent: The anticipated risks and benefits were discussed with the patient for all treatment options as a component of the elements of informed consent which was obtained verbally SUBJECTIVE History of present condition: Russell J Newton is a 61 year old male who is being seen today for physical therapy evaluation as part of the ALS Multidisciplinary Clinic at University Hospital. The patient has the company of only himself in attendance today. For this multidisciplinary clinic visit, the level of pain if present, medications, allergies, social history, and learning assessment was conducted by clinic staff and documented. This is the patient's first multidisciplinary clinic visit. Subjective: SOCIAL SUPPORT/ENVIRONMENT: The following was taken from the pre-screening phone call: Lives in a house which is wheelchair accessible when entering from the garage. Bedrooms are upstairs, he is going to install a lift, or will stay in Texas home which has everything on one level but two steps to enter. Lives alone. "I am not planning on being in a wheelchair." Patient indicates that he expects to stop breathing from his disease before he would need a wheelchair. Details of Falls: denies Prior Level of Function / Current functional limitations: . Independent with: all functional mobility and ADL's. Requires assistance with: nothing Durable medical equipment currently needed for this condition: none Exercise and leisure status/Home responsibilities: denies exercising, walks about a mile and a half per day. PRIOR THERAPY SERVICES FOR CURRENT CONDITION: The patient has not had prior therapy services for this current condition. Past medical and surgical history: Past Medical History:DiagnosisDate•ALS (amyotrophic lateral sclerosis) •Hyperlipidemia •Prostate cancer Past Surgical History:ProcedureLateralityDate•PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) 11/2020 OBJECTIVE Examination: Posture: no gross deviations Range of Motion: Lower Extremity ROM: Active DF at least to neutral bilaterally, though patient endorses catching his toes (typically right) on the ground roughly once per day, always late in the day, stumbles a little bit, always able to catch himself. Strength: Lower Extremity: Strength Lower Extremities Movement Strength Tests Left LE: Completed L Hip Flexion: 4+/5 L Knee Extension: 5/5 L Knee Flexion: 5/5 L Ankle Dorsiflexion: 5/5 Movement Strength Tests Right LE: Completed R Hip Flexion: 4+/5 R Knee Extension: 5/5 R Knee Flexion: 5/5 R Ankle Dorsiflexion: 5/5 Neuromotor assessment: No deficits observed Balance assessment: Dynamic Gait Index (DGI):. Patient's Total Score: 24 /24. Gait Device Used: No assistive device. The individual item scores for the DGI are as follows: 1. Walk:3/3 - Normal: Walks 20’ without assist. device, good speed, no evidence for imbalance, normal gait pattern. 2. Change Speed:3/3 - Normal: Able to smoothly change walking speed without loss of balance or gait deviations. Shows a significant difference in walking speeds between normal, fast, and slow speed. 3. Gait with Horizontal Head Turns:3/3 - Normal: Performs full head turns smoothly with no change in gait pattern. 4. Gait with Vertical Head Turns:3/3 - Normal: Performs full head turns smoothly with no change in gait pattern. 5. Gait and Pivot Turn:3/3 - Normal: Pivot turns slowly within 3 seconds and stops quickly with no loss of balance. 6. Step Over Obstacle:3/3 - Normal: Is able to step over obstacles without changing speed or evidence of imbalance. 7. Steps Around Obstacle:3/3 - Normal: Able to walk around obstacles without changes in speed or gait pattern (continuous steps), no evidence of imbalance. 8. Steps (Ascend and Descend):3/3 - Normal - alternating feet, no rail. Cut-off Scores: Older Adults: 20 - 24 = Normal Performance. 17 - 19 = Increased risk for falls. 0 - 16 = High risk for falls. (Shumway-Cook & Woollacott, 1995) Minimal Detectable Change: Population MDC Community-dwelling Elderly: 2.9 points (Romero, et al. 2011) Stroke: 2.6 points (Jonsdottir & Cattaneo, 2007): Parkinson's Disease: 2.9 points (Huang, et al. 2011) Hoehn and Yahr I-III Multiple Sclerosis: 5.5 points (Cattaneo, et al. 2007) Vestibular Disorders: 3.2 points (Hall & Herdman, 2006) The DGI is a measure of dynamic control of locomotion. The test may be performed with an assistive device. Gait Velocity Assessment: Measure:Patient Data Pace:self-selected, casualGait Device:No assistive deviceFootwear:shoes onOrthotic::noneDistance:30' (914.4 cm)Surface: low pile carpetAmbulation Time:8.2 secondsVelocity: (mph)2.494 mphVelocity: (m/s)1.12 m/s Required Velocity for Functional Ambulation: Daily Life ActivityTypical Velocity Crossing a Street:2.68 mph1.21 m/sNormal Casual Gait:2.20 mph0.99 m/sUnlimited Community Ambulation:1.78 mph0.80 m/sUnlimited Household Ambulation:0.60 mph0.27 m/sIndependent on All Surfaces:1.45 mph0.66 m/sIndependent on Level Surfaces:0.89 mph0.40 m/sAble to Ambulate with Supervision:0.38 to 0.54 mph0.17 to 0.24 m/sAble to Ambulate with Physical Assistance:0.31 to 0.51 mph0.14 to 0.23 m/sIndependent with ADL:2.2 mph0.99 m/sLess Likely to be Hospitalized:2.2 mph0.99 m/sLess Likely to Fall2.2 mph0.99 m/s Comments: Mobility Assessment: Bed mobility: patient reports he is independent with this, not assessed today. Transfers: Patient is able to stand from a standard height chair without upper extremity support with good control and stability Ambulation: no gross deviations Education/Home exercise program: Continue to do functional activities and stay active, try not to "over-do" it, should feel well-rested the next day. ______________________________________________________________________ Treatment provided and billed services: Based on personal factors involved, systems assessed, characteristics of the clinical presentation, and level of clinical decision making required, the complexity of the evaluation performed today is determined to be: Low Complexity Evaluation: 28 minutes TIMED CODE TREATMENT: 0 minutes TOTAL TREATMENT TIME: 26 minutes Laura M Guse, PT, PT, DPT, NCS Outpatient Neuro Therapy Team UW Health Rehabilitation Clinic 6630 University Avenue Middleton, WI 53562 Phone: 608-263-8412 Fax: 608-263-5011
Patient Instructions - Clinical Notes
Physical Therapist Laura G at 07/16/21 0830
ALS and Exercise
General Exercise Recommendations:
Feel fully recovered the next day
It is normal to feel tired/weaker right after exercising
You should feel fully recovered when you wake up the next day
If you don't, decrease the intensity or amount that you did
The weakness you feel afterwards should not interfere with your function
If you cannot walk, get out of bed, get out of a chair, or take care of yourself due to the weakness or fatigue from exercising, you did too much
Give yourself 1-2 days between workouts
Allows full recovery and limits issues with fatigue
Strengthening:
Only strengthen if you can move limb fully against gravity (Your PT can help assess this)
Avoid soreness after exercise
This indicates that there was muscle tissue tearing and you may not be able to fully recover from this. This may result in the muscle getting weaker
Aerobic Exercise (Cardio)
Work up to 75% of maximal effort level
Pushing to maximal effort level can be unsafe
You still should feel like you are working. You should feel mildly out of breath while exercising
Try to reduce stress on joints
Use stationary bike or NuStep instead of walking/running if able
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