SEMINAR 1: WRITING YOUR WRITTEN CASE REPORT
To facilitate your PT professional decision-making process, written case reports will be
one of the learning activities employed in Seminar 1.
To guide you on how to write this report, the following questions are to be answered.
Some tips are also given on how best to answer these questions.
o Points of Emphasis in Examination
ain !uestion"
- #hat areas of the PT $%amination process would be necessary for you to
make a comprehensive evaluation of this case& 'e as specific as possible
(i.e., palpation of wrist)hand e%tensor muscles, *+ of thumb, ,- of ankle,
etc...
Tips"
- The points of emphasis in e%amination are the specific components of your
patient e%amination that would give significant findings as to your specific
case.
- /f you have the sample /nitial $valuation format, you can 0ust list down the
specific components from the Sub0ective and +b0ective portions that would be
significant for this case. 1fter listing, you can e%pound on each item on the list
as to the specific things you would look for.
o Prob!m "ist
ain !uestion"
- #hat would be the problems, as evidenced by the findings of the necessary
areas of the PT $%amination process, which can be addressed by you, the
PT-in-charge&
Tips"
- *emember that this is 0ust a summary ) list of the significant findings gathered
from your patient e%amination.
- 2ou can base this list from the findings that you can e%pect in your 3Points of
$mphasis in $%amination.4
o PT #ia$nosis
ain !uestion"
- #hat would be the appropriate PT 5iagnosis for this case&
Tips"
- #hen writing down the PT 5iagnosis, this should be the PT diagnostic label,
and not the components of the e%amination.
o Pan of Car! %PT Goas&
ain !uestion"
- 'asing on your Problem ,ist, what would be the appropriate PT -oals for
each of these problems&
Tips"
- This would be your list of goals to address your 3Problem ,ist.4
- /t would be best to identify at least one (1. goal for each identified problem.
o Int!r'!ntion
ain !uestion"
- 'asing on the PT -oals that you identified, what would be the appropriate PT
/ntervention(s. that could help you achieve each of these goals& 'e as
specific as possible (i.e., to reduce pain on hip" icing for 16-17 minutes over
painful area, to prevent recurrence" patient education on proper handgrip
si8es and appropriate warm-up stretches to the wrist)hand e%tensor muscles..
Tips"
- This would be your list of appropriate PT interventions that could achieve your
3Plan of 9are (PT -oals..4
- /t would be best to identify at least one (1. PT intervention for each identified
goal.