8/12/2019 Paciente Amputado Caso Clinico

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TIME OF THE ILLNESS: 2 YEARS(2003-2005)

FORM OF INITIATION: car accident

EVOLUTION OF THE ILLNESS: None

MAIN SINGS AND SYMPTOMS: problems with coordination, balance

CHRONOLOGICAL REPORT

THE PATIENT WITH ANTECEDENTS OF DIAGNOSIS OF: Partial left foot traumatic amputation

REFERS BEGINNING him ILLNESS 2years AGO WITH: No pain

PRESENTING AT THE MOMENT OF him INCOMING: no signs and symptoms

FOR THAT REASON IT IS TAKEN: vs: normal

THE INMEDIATE INTENTIONS WERE: None

1)

1. The patient came to rehabilitation clinic at 9:00 am2. He was attended and checked3. The clinic chart was prepared and filled with the information get from the patient4. Is taking patient vital signs immediately5. He was prepared for a preprosthetic exercise program6. the patient should continue strengthening exercises muscle7. The patient should follow a low calorie diet (vegetables, water, lean meats)8. The patient should not drink alcoholic beverages, do not smoke or take drugs9. The patient was sent home at 12:00am

2)

Amputation of his left leg was due to a vehicular accident

The amputation caused muscle weakness

The lack of coordination was caused by amputation

The lack of balance was caused by amputation

3)

The male patient present partial left foot traumatic amputation for a car accident

8/12/2019 Paciente Amputado Caso Clinico

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