Problem Mapping CASE 1

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PROBLEM MAP

PT MANAGEMENT:

LOM of (L) shoulder towards flexion, abduction and ER

Pt will have an increase ROM with 5 degrees increments every tx session, in order to perform overhead activities with minimal limitation

• AROMES of (R) shoulder towards flexion and ABD and ER in pain free range x 10 reps x 1 set, OD • GPS of shoulder towards flexion, abduction, ER, & IR using hold relax technique x 6sh x 10 reps x 1 set

Pain on (R) shoulder (VRS = 6/10) and ADL difficulty

Pt will have a decrease in pain form VRS 6/10 to 2/10 after 2-3 tx sessions, in order to perform full range of motion and be able to wear UE garment with minimal to no pain

• HMP and TENS on ® Shoulder x 15 mins Pt education about proper body mechanics ADL Modifications

PRIORITIZED PROBLEM LIST:

.................................................SHORT-TERM GOAL/S:

...........................................................................................................TREATMENT:

TREATMENT OUTCOMES (i.e. Summary or Line Graph of ICF Progress Monitoring Sheet):

FINAL PT DX/PT IMPRESSION: Moderately Impaired Muscle Performance, and mildly impaired Range of Motion Associated With L Rotator Cuff Tendinitis, Bicipital Tendinitis

PT PROGNOSIS (i.e. Final/Overall Rehabilitation Potential): FAVORABLE All clinical presentations are manageable by PT rehab. The main concern is the proper healing of the affected soft tissue structures. Management of pain and education of proper body mechanics would suffice to make the long term goal of patient favorable.

LONG-TERM GOAL:

Pt will be able to preform ADL activities with minimal VRS 2/10 to no pain VRS 0/10 after 1 month of PT sessions

CLINICAL BUNDLE C: IMPAIRED MOTOR FUNCTION

ADL DIFFICULTY: Pt has difficulty in cleaning backyard the requires lifting of heavy objects in elbow flexed position then lift it overhead to transfer it to the garbage bin, playing table tennis that requires ER and IR of SH, billiards that requires Elbow flexion, and overhead activities such as donning and doffing of UE garment dressing due to Intermittent localized dull aching pain on ® Shoulder elicited during overhead activities and Shoulder extension (PS 6/10)

CLINICAL BUNDLE B: IMPAIRED MUSCLE PERFORMANCE

(-) decreased mm strength

CLINICAL BUNDLE A: IMPAIRED ROM

DIFFERENTIAL PT DX (i.e. Pattern Exclusion): Impairments associated with hemarthrosis

(-) hard end-feel

(+) LOM towards R Shoulder flexion, abduction, ER and IR due to pain

PERTINENT FINDING A (i.e. - Pattern Inclusion, Direct/Indirect Impairments, Activity Limitations, or Participation Restriction Including Other Associated Pertinent Postitive/Negative Findings per Clinical Bundle)

ASSESSMENT/EVALUATION (i.e. ICF-Based Interpretation and/or Running PT Dx. per Clinical Bundle):

PROGNOSIS (i.e. Running Medical Prognosis and Rehabilitation Potential per Clinical Bundle)

PATIENT ILLNESS SCRIPT: MECHANISM: repetitive overhead activities EPIDEMIOLOGY: MALE, 67 yo DURATION: SUB-ACUTE PHASE CLINICAL PRESENTATION: Patient has difficulty using his ® Shoulder in performing ADLs as to UE garment dressing and difficulty finding a comfortable position that would not elicit the pain but when elicited there is Intermittent localized dull aching pain on ® Shoulder(PS 6/10) Pt. has LOM Shoulder flexion, abduction, ER and IR due to pain INITIAL PT DX/PT IMPRESSION: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With L Rotator Cuff Tendinitis, Bicipital Tendinitis

ASSESSMENT PLAN (based on Chief Complaint and Subjective/Preliminary Objective Data): PAIN SCALE ADL ANALYSIS ROM Assessment MMT POSTURAL ANALYSIS SPECIAL TESTS

DISEASE ILLNESS SCRIPT: MECHANISM: ROTATOR CUFF TENDINITIS - due to mm imbalances within the shoulder complex either due to a structural deformity within the acromion process, weakness of the shoulder stabilizers; rotator cuff mm and deltoids, and repetitive overhead activities causing irritation to the rotator cuff tendons causing chronic inflammation within the soft tissue BICIPITAL TENDINITIS - due to structural anomalies of the bicipital groove, usually being shallow causing easy translation of the long head of biceps tendon away from the groove. Repetitive use of the biceps brachiimay also irritate the tendon and may cause inflammation EPIDEMIOLOGY: BOTH: athletes that requires overhead activities. Can affect any age group. DURATION: ACUTE, SUB-ACUTE and CHRONIC CLINICAL PRESENTATION: ROTATOR CUFF TENDINITIS: weakness of the rotator cuff mm, pain upon motion of the shoulder BICIPITAL TENDINITIS: localized pain at the bicipital groove, weakness of the biceps and rotator cuff mm, painful motion of the shoulder and elbow MEDICAL DIAGNOSIS: ROTATOR CUFF TENDINITIS and BICIPITAL TENDINITIS