Mr. G. suffered a back injury at work and is completing three weeks of physical therapy.

Mr. G. Case Study

Mr. G. suffered a back injury at work and is completing three weeks of physical therapy. Since he has been unable to work, he attends physical therapy (PT) three times per week with his physical therapist, Gina. She is a recent graduate and has been working at this clinic for four months.

After Mr. G.’s ninth treatment, his physician explains that he has made good progress and no longer needs PT. Still unable to return to his physically demanding job, he continues the home exercise program with instructions from the physician to call if he has further problems.

One month later, Mr. G. calls his doctor and reports that he had a “flare up” in his lower back, and the doctor orders another round of PT — three times per week for four weeks. During a session with Gina, Mr. G. mentions that he had slipped and fallen on a rainy night while coaching his daughter’s soccer team a couple of days before the “flare up.” Gina asks if his doctor knows about this latest fall.

Mr. G. replies, “No, why would he? Anyway, I was having some painful twinges in my back before I slipped. Besides, I fell on grass. I’m sure I did not hurt myself when I slipped. The doctor told me that I may need extra PT anyway.”

When Gina sees Mr. G. at his next session, he complains of increased pain with radiation down his left leg. During her evaluation, Gina concludes that his current pain differs from the pain of the first fall and is certainly related to this recent injury. She explains this to Mr. G. and suggests that he see his doctor to get proper evaluation and treatment. Mr. G. insists that he does not want to bother his doctor.

On his next visit, Mr. G. seems visibly fatigued and irritable. He complains about weakness and numbness in his left leg. Gina strongly urges him to talk with his doctor, but the patient again refuses.

“Well, perhaps I should talk to the doctor for you. I could tell him about your fall at the soccer game and the onset of numbness and weakness in your leg. You know the doctor looks at the notes that I write,” Gina suggests.

“No,” yells Mr. G. “I do not want you to say anything. It is none of your business. I do not want to bother him, and you must respect my wishes. Your job is to do this physical therapy and not to interfere.”

1. What should Gina do now and why?

2. What might Gina have done earlier?

3. How would you have handled this patient? Answer below:

I am completely lost on this case study because there are HIPPA laws but then i believe the PT could tell the physician right since the physician referred the patient?