Client Name: Jessica Date: 2018-01-28

S- Client arrived at clinic for a complete decongestive physical therapy session at 10:30am. Pt
states she is “really frustrated that she is still having difficulty with dressing, cooking, and others
ADL’s. Her daughter is having a formal and she really wanted to make her a dress but is unable
to sew at present.” Pt reports “she just wants to get back to her life before cancer and is feeling
down recently”. Pt has no contraindication to therapy plan, and gave verbal consent to engage
in therapy session.------------------------------------------------------------------------------------------------------
O- Pt presents with stable vitals signs: HR 80bpm, and BP 115/65, PTA observed swelling in
L/UE. Pt stated her pain level before beginning tx was 2/10. PTA begins by inspecting the skin,
and reviews meticulous skin care routine with pt including the use of low pH level lotion to
cleanse the skin emollients to keep the skin supple, as well as careful drying of the skin. PTA
then moved onto the manual lymph drainage massage to increase movement of lymph. PTA
used a combination of stationary circles, pumping, scooping, and rotary strokes. Strokes last 1
second each, repeated 7 times, applied toward the intact lymphatic pathway, starting
proximally, moving distally. PTA exerted very light pressure to avoid compressing and closing
the lymphatic channels. This portion of the session lasted 40 minutes. PTA then used
compression garments, pt has custom fit garment with 30 mmHg on L/UE. PTA then performed
exercises with the pt on the L/UE, with the compression garment on. PTA instructed patient to
perform AAROM of the L/UE, in all ranges of the shoulder including: shoulder flexion,
extension, external and internal rotation, abduction, and adduction. Ranges were performed 10
reps each. After this, the PTA instructed the pt to do AROM, pt was able to perform all ranges
of motion independently. Pt stated she felt mild pain during tx session, at 5/10 pain.-------- -------
A -Pt tolerated tx well, vitals were recorded after tx, and vitals were stable HR 84bpm and BP
116/67. Pt stated she had mild pain during tx, but pain resolved after tx was completed. Pt was
able to perform AROM in all directions of shoulder movement. Once tx was complete pt stated
pain level had decreased from during the session 3/10, which is 1 level higher from before tx
session. --------------------------------------------------------------------------------------------------------------------
P- Discuss tx session with PT, continue to work towards therapeutic goals. Inform PT of
patient’s mild pain during therapy session. Next session to be on 2018-02-02 at 10:30 am. -------
---------------------------------------------------------------------------Ashleigh Cole (DC OTA/PTA student)----
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