Physical and Occupational Therapy
SY 2021-2022
Case Analysis
Instruction: Answer the following guide questions for every case given and make a
hypothetical case out of the diagnosis you make.
1. Diagnosis
● What condition produces the patient’s symptoms? & Why?
● An injury was most likely sustained to which structure?
2. Inference
● What is the most likely contributing factor in the development of this condition?
Why?
3. Confirmation
● What is the most likely clinical presentation?
● What laboratory or imaging studies would confirm the diagnosis? Why?
● What additional information should be obtained to confirm the diagnosis? Why?
4. Examination
● What history should be documented? Why?
● What tests/measures are most appropriate? Why?
● What additional findings are likely with this patient? (Complications) why?
5. Management
● What is the most effective management of this patient? (Medical, Surgical,
Pharmacological and other health care management) why?
● What home care regimen should be recommended? (HEP and Pt. Education)
why?
6. Outcome
● What is the likely outcome of a course in physical therapy?
● What are the long-term effects of the patient’s condition? (Prognosis)
7. Comparison
● What are the distinguishing characteristics of a similar condition? (Differential
Diagnosis-tabulate) why?
Case #1. A 25-year-old female has been hospitalized for one week due to weakness. Upon
history taking, she mentioned she has a previous respiratory infection. The Patient’s strength
assessment reports 3-/5 bilateral hip strength, 2+/5 bilateral knee strength, and 2-/5 bilateral
ankle strength. The Patient is anxious to improve and is eager to begin physical therapy. The
patient resides alone in a second-floor apartment and works as a bank teller.
Case #2. A 28-year-old female has recently had visual difficulty, urinary urgency, tingling, and
upper extremity weakness on two separate occasions. The patient has an aunt with the same
condition, however, has no other significant medical history. The patient was referred to physical
therapy by her primary physician.
Case #3. A 25-year-old male was injured when he was hit from behind. the blow produces
cervical hyperextension and bleeding within the central gray matter of the spinal cord. The
patient’s diagnosis is consistent with the manifestations presented by the patient, impaired
coughing and ability to clear secretions, altered breathing pattern, and poor endurance. He was
referred to Physical Therapy. The patient resides alone in a second-floor apartment and is a
full-time graduate student.
Case #4. A 42-year-old female was in a motor vehicle accident and was admitted to the hospital
and was referred to Physical Therapy. She manifested with a localized response, response to
physical discomfort, and inconsistent response to commands. The accident was 2 weeks ago.
Prior to admission the patient was healthy and worked full-time. She has a supportive husband.
Case #5. A 56-year male is diagnosed consistently with the following manifestation including
asymmetric muscle weakness, cramping, and mild atrophy of the hand. The patient owns his
own business as a painter and wants to continue working for as long as he can. The patient is
referred to physical therapy for a home exercise program.
