Free Medical Rehabilitation Case Report Template
Medical Rehabilitation Case Report
1. Introduction
This medical rehabilitation case report template is designed to provide a comprehensive overview of a patient's rehabilitation journey. It includes sections on patient information, medical history, rehabilitation goals, interventions, outcomes, and follow-up care. The use of structured headings, paragraphs, tables, and lists ensures clarity and thorough documentation of the rehabilitation process.
2. Patient Information
|
Patient ID |
001234 |
|---|---|
|
Age |
45 |
|
Gender |
Male |
|
Date of Admission |
2090-09-01 |
|
Date of Discharge |
2090-10-15 |
3. Medical History
A. Pre-existing Conditions
A patient has a history of hypertension and type 2 diabetes, managed with medication and lifestyle changes. Previous surgeries include an appendectomy at age 22 and rotator cuff repair at age 38.
B. Current Diagnosis
The patient was admitted following a cerebrovascular accident (stroke) affecting the left hemisphere, resulting in right-sided hemiparesis and speech difficulties (aphasia).
C. Medication
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Lisinopril 10mg daily for hypertension
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Metformin 500mg twice daily for diabetes
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Aspirin 81mg daily for stroke prevention
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Atorvastatin 20mg daily for cholesterol management
4. Rehabilitation Goals
A. Short-term Goals
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Increase right arm and leg strength to facilitate independence in basic activities of daily living (ADLs).
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Improve communication skills to enable basic verbal interaction.
B. Long-term Goals
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Restore full mobility to return to work as an accountant.
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Achieve full independence in ADLs and instrumental ADLs (IADLs).
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Gain fluency in spoken communication.
5. Interventions
A. Physical Therapy
Intensive daily sessions focusing on strength, balance, and coordination exercises. Use of modalities such as electrical stimulation and ultrasound therapy to enhance recovery. Progressive exercise program designed to improve motor control on the affected side.
B. Occupational Therapy
Includes retraining in ADLs such as dressing, grooming, and feeding. Use of adaptive equipment to facilitate independence. Focus on improving fine motor skills and hand-eye coordination.
C. Speech-Language Therapy
Sessions to improve speech articulation and language comprehension. Use of linguistic exercises, speech drills, and augmentative communication devices to aid recovery.
D. Additional Support Services
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Psychological counseling to address emotional and cognitive challenges post-stroke.
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Nutritional counseling to support overall health and manage diabetes.
6. Outcomes
A. Functional Improvements
The patient achieved significant improvement in functional mobility, with a noted increase in muscle strength and balance. Independence in basic ADLs was achieved, with partial restoration in IADLs.
B. Communication Enhancements
The patient exhibited marked improvement in language comprehension and speech clarity, enabling effective basic communication.
C. Emotional and Cognitive Status
The patient demonstrated improved mood and coping mechanisms, although some cognitive deficits remain, requiring ongoing support.
7. Follow-up Care
Scheduled outpatient therapy sessions three times a week to continue progress in physical and speech therapy. Monthly follow-up appointments with a rehabilitation physician to assess and adjust management plans as needed. Continuous psychological support and community integration programs are recommended.
8. Conclusion
This case report highlights the comprehensive approach to rehabilitation for a patient post-stroke, emphasizing the importance of an interdisciplinary team. Through targeted interventions, consistent follow-up, and patient dedication, substantial progress was achieved, improving the patient's quality of life and potential for full recovery.
