Case Study Forms for Advanced Course

Patient Case Form  I

Therapist name:___

Email: _________

 

Please check all that apply:

 

Etiology of lymphedema:

__Primary, present from birth

__Primary, of later onset

__Secondary to treatment for cancer:  __breast  __melanoma  __cervical  __Face/throat  __lymphoma

__ovarian  __testicular  __prostate  __vulvar  __OTHER:_____________________________________

__Secondary to trauma

__Secondary to non-cancer related surgery

__Lipo-lymphedema

__Obesity induced lymphedema

__Secondary to venous problems

__Peri-wound edema

__Other:

__Etiology unclear

__Not a lymphedema case; diagnosis/etiology:

 

Location of swelling  (check all that apply)

__Upper extremity __hand very involved  __hand only    __upper arm only  __forearm only __bilateral

__Lower extremity __Toes very involved  __foot/ankle only  __leg below knee only  __thigh only __bilateral

__truncal  __lower trunk  __abdomen  ___chest wall  __breast(s) __scapular area __lateral trunk

__Genital  ___male  ___female

__Face/neck  __tongue involved    ___Neck only, no facial swelling   ___eyelids involved   __with trach

 

Special issues

__Pediatric

__Palliative

__Non-healing wound

__Active cancer

__Skin disorder:

__Morbid obesity

__Many co-morbidities:

__Other disabilities:

__Other

 

 

Patient not able to do full treatment

__compliance/motivation

__transportation/time/family or employer support issues etc

__insurance coverage issues

__cognition

__palliative care/terminal patient

__skin sensitivities/low tolerance for compression

__co-morbidities included contraindications/concerns re full treatment

__patient unable to do self-care and has no help at home

__bandaging   __home MLD   __exercises   __skin care/hygiene  ___garment donning

 

Why did you select this case?

 

 

Patient Case Form  II

Therapist name:________________________________________ Email: _________________________________

 

Please check all that apply:

 

Etiology of lymphedema:

__Primary, present from birth

__Primary, of later onset

__Secondary to treatment for cancer:  __breast  __melanoma  __cervical  __Face/throat  __lymphoma

__ovarian  __testicular  __prostate  __vulvar  __OTHER:_____________________________________

__Secondary to trauma

__Secondary to non-cancer related surgery

__Lipo-lymphedema

__Obesity induced lymphedema

__Secondary to venous problems

__Peri-wound edema

__Other:

__Etiology unclear

__Not a lymphedema case; diagnosis/etiology:

 

Location of swelling  (check all that apply)

__Upper extremity __hand very involved  __hand only    __upper arm only  __forearm only __bilateral

__Lower extremity __Toes very involved  __foot/ankle only  __leg below knee only  __thigh only __bilateral

__truncal  __lower trunk  __abdomen  ___chest wall  __breast(s) __scapular area __lateral trunk

__Genital  ___male  ___female

__Face/neck  __tongue involved    ___Neck only, no facial swelling   ___eyelids involved   __with trach

 

Special issues

__Pediatric

__Palliative

__Non-healing wound

__Active  cancer

__Skin disorder:

__Morbid obesity

__Many co-morbidities:

__Other disabilities:

__Other

 

 

Patient not able to do full treatment

__compliance/motivation

__transportation/time/family or employer support issues etc

__insurance coverage issues

__cognition

__palliative care/terminal patient

__skin sensitivities/low tolerance for compression

__co-morbidities included contraindications/concerns re full treatment

__patient unable to do self-care and has no help at home

__bandaging   __home MLD   __exercises   __skin care/hygiene  ___garment donning

 

Why did you select this case?

 

__Skin disorder:

__Morbid obesity

__Many co-morbidities:

__Other disabilities:

__Other

 

 

Patient not able to do full treatment

__compliance/motivation

__transportation/time/family or employer support issues etc

__insurance coverage issues

__cognition

__palliative care/terminal patient

__skin sensitivities/low tolerance for compression

__co-morbidities included contraindications/concerns re full treatment

__patient unable to do self-care and has no help at home

__bandaging   __home MLD   __exercises   __skin care/hygiene  ___garment donning

 

Why did you select this case?