Patient Illness Script
Initial PT Diagnosis/PT Impression
Final PT Diagnosis/PT Impression:
Patient has minimally impaired posture, maximally impaired ROM and motor function brought about by (L) Adhesive Capsulitis, ® Rotator Cuff Tendinitis, Trigger finger on 2nd digit of ® hand
PT Prognosis
Patient has a good prognosis since all of her impairments could be addressed by physical therapy.
Long Term Goal
Patient will be able to perform ADLs independently with minimal pain and difficulty on the (L) shoulder after 2 weeks of tx sessions.
5. Postural deviation
To maintain proper body mechanics throughout treatment
• Postural Reinforcements
• Shoulder rolls x 10 reps (Ant and Post) x 1 set
• Shoulder retraction x 6 sec hold x 10 reps x 1 set
• Chin tucks x 6 sec hold x 10 reps x 1 set
4. ADL difficulty
ADL difficulty will be from maximal/moderate difficulty to minimal difficulty after 3 tx sessions
• ADL modifications
• Compensatory techniques
• Energy conservation
3. Decreased mm strength and mm weakness
Patient will have an increase in muscle grade by 1 after 6 tx sessions
• PREs on (B) shoulders toward AP using 1 lb DB x 10 reps x 2 sets
• Wall Isometric exercises on (B) UE x 6 sec hold x 10 reps x 1 set
2. LOM
Patient'sROM will increase by 10 increments after 6 tx sessions
• Stretching of (B) shoulder towards AP x 30 sec hold x 5 reps
• AROMES of (B) UE towards AP x 10 reps x 2 sets
• Wand exercises towards flexion on (B) shoulders x 10 reps x 2 sets
1. Constant deep aching pain on the (L) shoulder (PS 8/10) and constant dull aching pain on the ® shoulder (PS 5/10) and Trigger finger on 2nd digit of ® hand (PS 7/10)
Patient’s pain scale with decrease by 1 after 3 tx sessions
• US on (B) shoulders and scapular region x 1mhz x 2.5 w/cm2 x 8 min each
• HMP on (B) shoulder x 15 min
• Laser on (B) AC joint and trigger finger x 1 min
• PWB on ® hand x 15 minutes
• PJM Grade II distraction on (L) shoulder x 20 sec hold x 5 reps x 1 set
• Tendon gliding on ® hand
Problem
Clinical Bundle C (Posture)
Diagnosis: Minimally impaired posture
Shoulders slightly protracted
Kyphotic posture
Forward head
Clinical Bundle B (Motor Function)
Diagnosis: Maximally impaired motor function
Moderate to maximal difficulty when doing UE/LE garment dressing, clasping bras, reaching overhead, cooking, bathing, lifting and carrying objects, and reaching behind her back.
(+) Atrophy on (L) UE
(+) Gait Deviation
Decreased mm strength and mm weakness of shoulder flexors, extensors, and abductors
Clinical Bundle A (ROM)
Diagnosis: Maximally impaired ROM
(+) LOM towards shoulder flexion, abduction, IR, ER
Mild swelling on (L) Forearm
(+) Taut bands on (B) upper traps and scapular region
(+) Nodules on (B) upper traps and scapular region
(+) Swelling on (L) arm
Grade 1 tenderness on ® shoulder
Grade 2 tenderness on (L) shoulder
(+) muscle guarding on (L) shoulder towards flexion and abduction
constant deep aching pain on the (L) shoulder (PS 8/10) and constant dull aching pain on the ® shoulder (PS 5/10) and Trigger finger on 2nd digit of ® hand (PS 7/10)
Medical Diagnosis:
(L) Adhesive Capsulitis, ® Rotator Cuff Tendinitis, Trigger finger on 2nd digit of ® hand
Clinical Presentation:
Chief Complaint: Patient complains of constant deep aching pain on the (L) shoulder (PS 8/10) and constant dull aching pain on the ® shoulder (PS 5/10) and Trigger finger on 2nd digit of ® hand (PS 7/10)
• (+) muscle guarding on (L) shoulder towards flexion and abduction
• Grade 2 tenderness on (L) shoulder
• Grade 1 tenderness on ® shoulder
• (+) Swelling on (L) arm
• (+) Nodules on (B) upper traps and scapular region
• (+) Taut bands on (B) upper traps and scapular region
(+) LOM towards shoulder flexion, abduction, IR, ER
Decreased mm strength and mm weakness of shoulder flexors, extensors, and abductors
(+) Atrophy on (L) UE
Mild swelling on (L) Forearm
(+) Postural Deviation
(+) Gait Deviation
Moderate to maximal difficulty when doing UE/LE garment dressing, clasping bras, reaching overhead, cooking, bathing, lifting and carrying objects, and reaching behind her back.
Duration: Maximum Protection Phase
Epidemiology:
- 53 y/o; Female
- Married
- (R) Handed
- Medication: (Tramadol, Losartan, Celecoxib, and Mefenamic)
-(+) Hospitalization (1995, Laminectomy due to a slip disk)
-(+) DM (Dx: 2012, controlled: Metformin)
-(+) HTN (Dx: 2014, controlled: Losartan) Non-smoker Non-alcoholic beverage drinker Eats a balanced diet
- Sleeps in supine or side-lying position to the ®. Wakes up 2-3 times a night due to pain on (L) shoulder
-Takes a bath using a tabo or shower head
- Stays at home most of the time these days and cooks, cleans, or watches TV
- Has a helper in doing household chores
Mechanism: Idiopathic
