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Case management file for two different clients

  1. Provide a profile of a medical and/or allied health professional who could be chosen to communicate with about the case study client outlined below. You will need to communicate with a medical and/or allied health professional in regards to clearance before prescribing an exercise program.
  2. This will depend on the type/s of medical and allied health professionals chosen – that is, if the person is only suited to treating patients of a medical nature, an additional letter and report to an allied health professional may be necessary. Outline their area of expertise to justify your referral to this medical and/allied health professional. Provide evidence of your communication with this medical and/or allied health professional.
  1. Using the above information, prepare a letter to a relevant medical and/or allied health professional in regards to the client’s results on his pre-exercise screening form. The letter is to contain an introduction and an overview of your requirements – that is, you will require clearance and guidance in order to deliver a fitness program for the client.
  1. Prepare a report to support this letter that outlines:
  • the results of the pre-exercise screening form and fitness test
  • request for clearance to perform these exercises and activities, and/or clearance to perform alternatives as suggested by the medical and/or allied health professional
  • the client’s fitness goals and your view on his goals
  • an outline of the client’s risk factors and why these risk factors are beyond your area of expertise.

Case study – Peter

Peter is a 51-year-old male client at the gym. He has been referred from a doctor. He was recently involved in a motor vehicle accident (three months ago). Peter suffered from a fractured tibia in the car accident, which was operated on, and then placed in a plaster of Paris cast for six weeks. He has recovered well from this operation. The bone is in good condition and cleared for exercise following some early rounds of physiotherapy. Peter’s doctor has recommended that he start going to the gym to get fit and healthy again. Prior to his motor vehicle accident Peter walked daily, but he has never exercised in a gym before. Peter reports feeling very tight in the calf muscles and ankle since the plaster was removed six weeks ago. Peter’s other health information, as provided by his doctor, includes:

  • a blood pressure reading of 142/92 bpm
  • asthma (he takes ventolin)
  • poor eating habits, such as frequent takeaway lunches at work and dinner, skipping breakfast.

Note: Although this doctor has suggested that Peter join a gym, you should still assume that you will require clearance from the relevant medical and/or allied health professionals prior to exercise testing and/or programming when considering Peter’s medical and health status.

This task involves the receiving of simulated referrals from medical and allied health professionals and making decisions as to what plan of action you might take in response to each referral. Each referral situation is provided as a case study.

Katherine X

Dr Jones is a local general practitioner. He has referred Katherine to you (as a fitness trainer) because he would like her to start exercising. Katherine is obese, reporting poor dietary habits, and has Type 2 diabetes. Her resting blood pressure is 145/91mmHg. Katherine has arrived at the gym to buy a membership based on Dr Jones ‘telling me to come and see you’. The referral letter is as follows:

Katherine X is a 57-year-old female patient who has recently been diagnosed with Type 2 diabetes. Katherine is still learning about this condition and would benefit from further education and lifestyle modification. Her blood pressure is 145/91mmHg and she has commenced medication to assist in this being reduced. She will need an exercise program to assist with management of her condition. She is 89kg and 168cm tall.

Task:

  1. Complete a pre-activity questionnaire form for Katherine, filling in the information that you expect she would be able to fill in based on the information provided by Dr Jones. (Note: Even though it would be Katherine who would normally complete this form, this task will help you to demonstrate the ability to record health information for Katherine based on Dr Jones' referral.) 
  2. Write a short report (approximately 500–750 words) outlining:
  3. a) Katherine’s risk factors, including calculation of her BMI for poor health
  4. You are to demonstrate a collection of evidence in a portfolio showing your ability to identify and refer clients requiring medical or allied health professional expertise. This task is most suited to students currently working in the fitness industry and who have been working collaboratively with medical and allied health professionals;

    1. Access information from at least three clients with health or medical concerns that require medical or allied health professional expertise. Use pre-test screening information and seek additional health information from the clients as required.
    2. Analyse health information to determine the need for referral and guidance. Recommend the client seek advice from medical or health professionals as required and arrange the referral with permission, consent and within confidentiality and privacy standards.
    3. Maintain a case management file with all documents, communication and collaboration with medical and allied health professionals.
    4. owever, your trainer may provide you with simulations as deemed appropriate, especially for those who have not had sufficient access to the required situations. Follow the instructions carefully to ensure you complete this task to the detailed level required. You will need to provide a variety of evidence, such as supervisor reports, letters, DVD recordings and so on. This assessment will need to be performed over a period of time to ensure you have adequate time to provide the evidence of competency required. 

      Task:

      You are to demonstrate a collection of evidence in a portfolio showing your ability to be part of an entire case management file for two different clients. The goal is to be part of a team that is managing a client for a particular concern, such as recovery after a motor vehicle accident or other injury, Type 2 diabetes management and so on. This should involve liaising with local medical and/or allied health professionals. An example of an appropriate case may include, but are not limited to the following:

      • a pregnant client who has been referred to the gym for an exercise program during her pregnancy
      • a postmenopausal client who has been referred to the gym for a weight-bearing cardiovascular program and a resistance program to minimise the risk of the onset of osteoporosis
      • a client you have referred who has presented to the gym with risk factors warranting guidance and clearance from a doctor. You then continue managing this client under the care and supervision of a doctor or allied health professional.

      Check your case management file is appropriate with your trainer before submission. You will need to submit all necessary documentation to support your claims of competency.

      Note: One of your cases should include receiving at least one referral, while the other case should involve you making at least one referral. Some cases may involve more than one medical and/or allied health professional. If the client is not officially ‘discharged’ from the medical and/or allied health professional, the case should be managed for at least two months to ensure adequate time to demonstrate competency in this task.

      Task:

      1. Identify information that needs to be recorded in the case management file.
      2. Identify information that needs to be shared with medical or allied health professionals and provide as required.
      3. Maintain current, complete, accurate and relevant client records for each client contac
Case management file for two different clients
  1. Report to support the letter:

According to the Screening report and fleetness test Pater has very poor eating habits. He often skips his breakfast or dinner. He also frequently takes launch and dinner within a short period. The irregular eating habit has made his digestion system weak and deficient. Peter has 27 BMI which is not very high.  However he has high blood pressure that frequently hinders his daily activities. He has chronic Bronco Infection that leads to Asthma. Currently he is taking ventolin for medication.  

The above latter is made to request for clearance from a general medical practitioner named Michael Drivas. This letter is intended to receive any suggestion from the practitioner about the regular physical activities of Peter. The goal of the fitness program is to improve the fitness of the Peter. The high blood pressure of Peter needs immediate weight losing and cardiac exercise. At the same time the fitness procedure should be concerned about the asthma problem of the client.

Peter recently has recovered from the tibia fracture which needs additional care and protection. The tibia is a valuable bone that helps him do any movement activity. Apart from that if the current condition needs any special activities or program, the identification of the requirement would be out of my expertise.  Any misguidance in this vulnerable condition of Peter can lead to risky condition or severe injury.

Part B  True/False – Risk factors (25 marks)

Select the correct answer.

True

False

1.     A referral from a fitness trainer to a general practitioner should note a current medical history of hospitalisation and infectious disease.

?     True

False

2.     Mononucleosis is not an infectious disease and clients are recommended to train during the illness.

True

?     False

3.     Pregnancy is always a cause for referral for clearance from a medical professional to conduct a fitness test and/or fitness program.

?     True

False

4.     A family history of a heart attack or stroke is one risk factor that contributes to the need for referral to a medical practitioner.

?     True

False

5.     Low-risk clients are men under 45 and women under 55, who are asymptomatic and have no more than one coronary risk factor.

True

?     False

6.     Moderate-risk clients have a known cardiovascular, pulmonary or metabolic disease and three coronary risk factors.

True

?     False

7.     High-risk clients will most likely require exercise guidance from a doctor and/or an accredited exercise physiologist.

?     True

False

8.     A recent myocardial infarction is an absolute contraindication to exercise testing.

?     True

False

9.     Unstable angina is an absolute contraindication to exercise testing.

?     True

False

10.   Acute myocarditis is inflammation of the cardiac muscle.

?     True

False


11.   Severe hypertension is always an absolute contraindication to exercise.

?     True

False

12.   Chronic infectious diseases, such as hepatitis, are relative contraindications to exercise and exercise testing.

?     True

False

13.   Neuromuscular conditions exacerbated by exercise are relative contraindications to exercise.

?     True

False

14.   Fitness trainers should refer current musculoskeletal injuries to an appropriate allied health professional, such as a physiotherapist.

?     True

False

15.   Diastolic blood pressure greater than 110mm/Hg at rest warrants medical referral.

?     True

False

16.   A Type 2 diabetic client will never require insulin as part of their treatment.

True

?     False

17.   The quadriceps muscles are made up of the rectus femoris, vastuslateralis and vastusmedialis only.

True

?     False

18.   Patellofemoral pain syndrome is a common dysfunction seen in clients with anterior knee pain.

?     True

False

19.   The Achilles tendon is responsible for connection of the gastrocnemius to the calcaneus.

?     True

False

20.   The Tibialis anterior is responsible for plantarflexion of the ankle.

?     True

False

21.   The equivalent bones in the foot and hand are tarsals and carpals respectively.

?     True

False

22.   High blood glucose levels are greater than about 1mmol/L.

?     True

False

23.   High blood glucose levels (greater than 15mmol/L that last longer than 24 hours may start to result in the signs of hyperglycaemia.

?     True

False

24.   Hyperglycaemia will not result in thirst.

True

?     False

25.   HDL cholesterol is known as the ‘bad cholesterol’.

True

?     False

Part C Case study – Referral   (15 marks)

This task involves the receiving of simulated referrals from medical and allied health professionals and making decisions as to what plan of action you might take in response to each referral. Each referral situation is provided as a case study.

Katherine X

Dr Jones is a local general practitioner. He has referred Katherine to you (as a fitness trainer) because he would like her to start exercising. Katherine is obese, reporting poor dietary habits, and has Type 2 diabetes. Her resting blood pressure is 145/91mmHg. Katherine has arrived at the gym to buy a membership based on Dr Jones ‘telling me to come and see you’. The referral letter is as follows:

Katherine X is a 57-year-old female patient who has recently been diagnosed with Type 2 diabetes. Katherine is still learning about this condition and would benefit from further education and lifestyle modification. Her blood pressure is 145/91mmHg and she has commenced medication to assist in this being reduced. She will need an exercise program to assist with management of her condition. She is 89kg and 168cm tall. 

PARQ

NAME Katherine

AGE   57 years old

PHONE  0421311757

ADRESS 22 MEREDITH STREET BANKSTOWN

EMERGENCY CONTACT DETAIL  SON, JAMES SMITH 04444666777

1/ Do you have, or have you had:

q  heart disease (please specify):

high blood pressure  

q  high cholesterol

q  diabetes

q  lung disorder (eg. asthma, emphysema) other cardiac problem (incl. pacemaker,):

q  no/ or none of the above.

2/ Have you ever been told you are at risk of:

q  heart disease  

high blood pressure

q  high cholesterol  

q   diabetes   stroke

q  no/ or none of the above.

3/ Have you ever been told that you have heart problems, eg.:

q  heart murmur   valve defect

q  racing heart   irregular beats

q  angina

q  other:

q  no/ or none of the above.

4/ Do you have, or have you experienced:

q  epilepsy   fainting   seizures

q  dizzy spells   convulsions 

q  no/ or none of the above.

5/ Do you experience sudden shortness of breath?

YES                    NO

6/ Have you ever had pain or pressure, either at rest or during exercise:

q  in the middle of, or on the left side of, the chest,

q  in the neck region,

q  at the left shoulder or down the left arm.

q  no/ or none of the above.

7/ Do you take any medications for (please name):

q  heart disease: ……………………………

q  Diabetes cholesterol:…………………………

q  blood pressure:…145/91mmHg………………………...

q  asthma, breathing problems: …………..

q  no/ or none of the above.

8/ Are you aged over 60 years of age:

q  Yes        No

 
   

 


9/ Do you have any joint or muscular problems that may affect your ability to train:

q  Yes        No

If yes, please explain:

10/ Do you have any other conditions or injuries that may affect your ability to train:

q  Yes        No

If yes, please explain:…………

strongly recommends that you consult your doctor and obtain medical clearance prior to commencing any exercise program, as a certain level of risk is inherit in any exercise program. Any information, instruction or advice obtained from Active8 staff may not be substituted for your doctor’s advice or treatment, and that any instruction or advice is obtained t your own risk. You agree to release and discharge Active8 & Richmond Club, it’s staff and directors from any and all responsibilities or liabilities from injury or illness arising from your participation in any activity undertake at Active8 or upon our advice.er required?

Client is: aged 18-60 and has no risk factors                                            >>>          cleared for moderate exercise prescription

Client responded to one or more of Cardio-Respiratory risks                 >>>          refer to Doctor for clearance

Signatures: Client:KATHERINE          Staff : ..MARIANNA SOFIANIDOU.....       Date: …16/5/18.

     

Write a short report (approximately 500–750 words) outlining:

  1. a) Katherine’s risk factors, including calculation of her BMI for poor health

  Obese,

poor eating habits,

Type 2 Diabetes,

High blood pressure 145/91mmHg 

  1. b) The relevance of BMI in this situation

She is 89kg and 168cm tall. In this situation she needs to have lower weight. Therefore, it is clear that this BMI condition also influences her blood pressure. In order to keep his blood pressure and body weight balanced, she needs to reduce her BMI below 28.5 instead of having BMI 31.5 

  1. c) a suggested management plan for Katherine

Screening report and fleetness test for Peter

Katherine is obese patient that must as soon as possible lose weight for her healthier future. The benefits she will get is not only to how she gonna feel but she will reduce all this risk factors she already has,such as Type 2 Diabetes. Also by reducing weight she will reduce her future problem with bones and joints and reduce risk of future cancer.She must reduce the amount of intakes she gets daily and exercising almost 4 days a week. Her BMI must range between 20-25 as per high and must be loose about 17 kg to reach approxematly 70 kg recommend for her high

  1. d) what guidance you will require from medical and/or allied health professionals prior to fitness testing and/or fitness programming for Katherine.
  • Client’s risk and needs:

 Katherine has several risk factors including Obese, poor eating habits, Type 2 diabetes and high blood pressure. The high BMI report represents her tendency of Obesity. Irregular eating habits with unhealthy food proportion have lead to this situation with Type 2 diabetes. This high weight is causing high blood pressure as well. If needed this high blood pressure of 145/91mmHg has to be cured with appropriate medication and other treatment.   

Exercise type:

Jogging – Cardio and locomotion based program to improve muscles and bone functionalities and  

Freehand exercise- to increase the flexibility of the body wing enhanced insulin acceptance

Regular Bicycling- Cardio based blood pressure reducing program

Regular Climbing stairs- Cardio based respiratory improvement program

Aerobics in alternative days- Fat burning exercise that reduces the blood pressure as well

Write referral letters for medical and/or allied health professionals in your local area that you might suggest that Katherine should see either before or during your time with her. Ensure you provide a rationale for your referral.

Practitioner Name        KATE HOLMES

Clinic                          INGRID ORTH DIETITIAN AND NUTRITIONIST

Re:          Client Name:        KATHERINE

                Client Address:    BANKSTOWN

                Client DOB:           57 YEARS OLD 

MY client KATHERINE X has presented to our business/service/facility with the goal of lose weight as her GP suggest she must exercise to reduce her health risk factors such as Type 2 Diabetes

KATHERINE information and measurements recorded during pre-exercise screening include the following:

Current Physical Activity level

 

NOT AT ALL

Sessions / week

 

Notes:

?     TYPE 2 DIABETES

?     BMI -OBESITY

?     HIGH BLOOD PRESSURE 145/91mmHg

?     UNDER MEDICATION

?      

Minutes / week

 

Intensity (low/mod/high/ vig)

 

Resting HR

Resting BP

Weight

BMI

31.5

Waist Circ

 

In response to her screening results I am requesting your guidance in relation to Katherine condition to enable me to ensure delivery of a safe and effective exercise program. KATHERINE NEED A EATING PROGRAM PLAN WICH WILL HELP HER TO REDUCE HER BODY WEIGHT AND REDUCE RISK FACTORS AS SUCH SHE IS SUFFER OF

Based on Katherine goals, I intend to have /her commence an exercise program consisting of the following:

Jogging – Cardio and locomotion based program to improve muscles and bone functionalities and  

Freehand exercise- to increase the flexibility of the body wing enhanced insulin acceptance

Regular Bicycling- Cardio based blood pressure reducing program

Regular Climbing stairs- Cardio based respiratory improvement program

Aerobics in alternative days- Fat burning exercise that reduces the blood pressure as well

Please assess Katherine condition and indicate any recommendations you may have in relation to her exercise program, including specific activities /she cannot or should not be undertaking at this time, or other relevant notes.

I/ will keep you informed of KATHERERINE’s progress and any major changes in /her condition.  To acknowledge you have received this referral, please complete this section:

 

Date Referral received:

16/5/18

Status of Referral:

*please describe action required in notes

Complete

Incomplete*

Practitioner Name:

KATE HOLMES

Contact person for follow up:

**please provide new contact details in notes

As above

New contact**

Practitioner Title:

DIETITIAN

Notes:

Practitioner Signature:

KATE HOLMES

Please include in notes any instructions you may have regarding follow up or progress reporting.

I/we welcome any advice you feel necessary and can be contacted by phone <123456789> during <9AM-5PM > or email <[email protected]> anytime.

Client Consent:

I give my permission for Professional/Business to communicate with the referring Practitioner and/or my GP regarding my health status and my progress relating to my exercise program.

Client Name:

Katherine x

       

Your Sincerely,

Business/Facility Opening Hours 9am-5pm

Part D 300 Portfolio – Make referrals 

You are to demonstrate a collection of evidence in a portfolio showing your ability to identify and refer clients requiring medical or allied health professional expertise. This task is most suited to students currently working in the fitness industry and who have been working collaboratively with medical and allied health professionals;

however, your trainer may provide you with simulations as deemed appropriate, especially for those who have not had sufficient access to the required situations. Follow the instructions carefully to ensure you complete this task to the detailed level required. You will need to provide a variety of evidence, such as supervisor reports, letters, DVD recordings and so on. This assessment will need to be performed over a period of time to ensure you have adequate time to provide the evidence of competency required.

Task:

  1. Access information from at least three clients with health or medical concerns that require medical or allied health professional expertise. Use pre-test screening information and seek additional health information from the clients as required.
  2. Analyse health information to determine the need for referral and guidance. Recommend the client seek advice from medical or health professionals as required and arrange the referral with permission, consent and within confidentiality and privacy standards.
  3. Maintain a case management file with all documents, communication and collaboration with medical and allied health professionals.

Client 1:

Name : Ashline Markov

Medical Details

Address: 21/A MEREDITH STREET BANKSHIRE

BP: 130/90 mmHg

Weight: 85

BMI: 32

Age:  32

Medical history

Date of appointment:  12 May, 2018

·         High Blood pressure

·         Obesity

·         Endocrine abnormalities

·         Unhealthy eating practice

Current issue

Pregnancy

Back neck pain and burning sensation

Uncontrollable Palpitation and accelerated heartbeat

 Agitation during the day time

Restlessness as well as sleeplessness while having excessive fatigue

Recommendation

Referral

·         Regular Walking

·         Vitamin E based Diet

·         Avoid hard work

·         Have mentally stress-less environment

·         Avoid any weight lift

As per the result of basic screening test It has been determined that the patent needs some expert advice and medication. I am referring the patient to Dr. Devid Willium (General Physician) for further treatment process.

Confidentiality and Privacy Standards: All the collected documents and personal details of the patient will be considered as the subject of chief Confidentiality and Privacy. The documents will be used only for medical and physiotherapeutic purposes.  

     

Name : Lorain Martin

Medical Details

Address: 12 WENWORTH AVE, SYDNEY

BP: 110/65mmHg

Weight: 67

BMI: 25

Age:  47

Medical history

Date of appointment:  20 May, 2018

·         Low weight

·         Osteoporosis

·         Chronic Cardiovascular disorder

·         Unhealthy Diet

Current issue

Post menopausal symptoms

Mild Breathlessness after any physical activity

Accelerated heartbeat

 Joint pain in pelvic bone, knee and elbow

Excessive Fatigue

Recommendation

Referral

·         Calcium Diet

·         Regular jogging

·         Balanced prescribed diet

·          Breathing Exercise

As per the result of basic screening test It has been determined that the patent needs some advance medical diagnosis, physiotherapy and medication. I am referring the patient to Dr. Jack Martin (Endocrinologist) for further treatment process.

Confidentiality and Privacy Standards: All the collected documents and personal details of the patient will be considered as the subject of chief Confidentiality and Privacy. The documents will be used only for medical and physiotherapeutic purposes. 

     

Name : Devid Marks  

Medical Details

Address: 33/A, WENWORTH LANE, BRISBORN

BP: 130/90mmHg

Weight: 79

BMI: 28

Age:  52

Medical history

Date of appointment:  20 May, 2018

·         Obese

·         Chronic Bronchitis

·         Arthritis

Current issue

Mild Breathlessness after any physical activity

Accelerated heartbeat

 Knee pain

Early Fatigue

Needs of Expert Supervision

Recommendation

Referral

·         Calcium Diet

·         Regular Cycling

·         Avoid Dust allergies

·          Breathing Exercise

As per the result of basic screening test It has been determined that the patent needs clearance from registered doctor about his current physiological condition. I am referring the patient to Dr. Devid Willium (General Physician) to ensure that the patient is ready to have next level physical activities in gym.

Confidentiality and Privacy Standards: All the collected documents and personal details of the patient will be considered as the subject of chief Confidentiality and Privacy. The documents will be used only for medical and physiotherapeutic purposes. 

     

You are to demonstrate a collection of evidence in a portfolio showing your ability to be part of an entire case management file for two different clients. The goal is to be part of a team that is managing a client for a particular concern, such as recovery after a motor vehicle accident or other injury, Type 2 diabetes management and so on. This should involve liaising with local medical and/or allied health professionals. An example of an appropriate case may include, but are not limited to the following:

  • a pregnant client who has been referred to the gym for an exercise program during her pregnancy
  • a postmenopausal client who has been referred to the gym for a weight-bearing cardiovascular program and a resistance program to minimise the risk of the onset of osteoporosis
  • a client you have referred who has presented to the gym with risk factors warranting guidance and clearance from a doctor. You then continue managing this client under the care and supervision of a doctor or allied health professional.

Check your case management file is appropriate with your trainer before submission. You will need to submit all necessary documentation to support your claims of competency.

Note: One of your cases should include receiving at least one referral, while the other case should involve you making at least one referral. Some cases may involve more than one medical and/or allied health professional. If the client is not officially ‘discharged’ from the medical and/or allied health professional, the case should be managed for at least two months to ensure adequate time to demonstrate competency in this task

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