Patient Illness Script

Clinical Bundle A (ROM)

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

Mild swelling on (L) Forearm

(+) LOM towards shoulder flexion, abduction, IR, ER

Diagnosis: Maximally impaired ROM

Clinical Bundle B (Motor Function)

Decreased mm strength and mm weakness of shoulder flexors, extensors, and abductors

(+) Gait Deviation

(+) Atrophy on (L) UE

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.

Diagnosis: Maximally impaired motor function

Clinical Bundle C (Posture)

Forward head

Kyphotic posture

Shoulders slightly protracted

Diagnosis: Minimally impaired posture

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.

Problem

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

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

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

4. ADL difficulty

ADL difficulty will be from maximal/moderate difficulty to minimal difficulty after 3 tx sessions

• ADL modifications
• Compensatory techniques
• Energy conservation

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