Consultation, Screening, and Delegation – Care Example

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"Consultation, Screening, and Delegation" is an inspiring example of a paper on care. This case involves my husband, a 52-year-old man who underwent surgery following a ruptured appendix when 8 years old. The patient resides in a private home on uneven terrain with his spouse only and works as a pool service outside a home on a part-time basis. His general health status remains good even though he presented a past social habit of smoking and finally quitting the habit in 1985. In addition, the patient continues to take alcoholic beverages every day with one drink on an average day.

He exercises or does physical activity twice a week on average for twenty minutes on an average day beyond normal daily chores or activities. The patient also indicated a family history involving various family members having cases of heart disease, stroke, diabetes, cancer, arthritis, and psychological illness. Most notable, the father of the patient suffered cancer at the age of 75 while the mother suffered stroke and arthritis at the age of 60 and 65 correspondingly. 1(p1) Other aspects regarding the patient’ s medical history include allergies, ulcers or stomach problems, and difficulty in sleeping.

In 2011, the patient began complaining of lower back pain which became triggered by excessive drinking which compressed disc. The condition presented also in the past and upon chiropractic, the problem became better. However, the problem keeps on repeating since then. The patient currently uses a pillow to support the lumbar along with taking a pain reliever which makes the problem better. Upon excessive drinking, the problem becomes worse. Seeking relief of pain and more mobility constitutes the patient’ s goals for seeking physical therapy.

He currently seeks the attention of an acupuncturist, chiropractor and a massage therapist for the problem. 1(p2) At the functional or activity level, the patient has difficulty with movement or locomotion as well as difficulty with home management such as shopping, house chores, and transportation or driving. Furthermore, he has previously taken ibuprofen for the condition for which he seeks physical therapy. Nonprescription medications used include Advil/Aleve, antacids, herbal supplements, and bromelain as well. Within the past year, the patient undertook blood tests, electrocardiograms, X-rays and urine tests for the presented condition.

Upon a system review of the patient, no edema was observed. Blood pressure stands at 120/70, heart rate at 54bpm and respiratory rate at 16. The patient’ s height is 6’ 3 and weighs 160kg. There exists a scar formation at the abdominal area which remains not impaired. Moreover, the patient’ s communication, orientation, behavioral responses, and learning styles stay unimpaired. Similarly, no impairments became established with regards to his musculoskeletal as well as neuromuscular systems. The patient best learn through demonstration and his education needs encompass safety, activities of daily living and an exercise program. 1(p 2)  Findings that would indicate a need for referral to another health care provider take into account the patient’ s family history, social or health habit, the nature of his work and functional status.

Such findings include a family history of cancer, excessive drinking, the activities involved in his work as pool service, difficulty with movement or home management and the current problem of lower back pain. An analysis of the previous physical therapy activities undertaken by the patient and associated outcomes as well as his medical or surgical history also indicates the need for a referral.

This includes ulcers or stomach problems along with the outcomes of massage, chiropractic, and acupuncture on the lower back pain. The use of nonprescription drugs by the patient also warrants referral since the problem of lower back pain could arise from the use of such drugs.


1. American Physical Therapy Association. Documentation Template for Physical Therapist Patient/Client Management: Outpatient Form & Systems Review. Alexandria, VA: American Physical Therapy Association; 2003:1-2

2. Goroll AH, Mulley AG. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. 6th ed. Philadelphia, PA: Wolters Kluwer Health; 2012:1023-1036.

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