Patients name: I.E.

Referring Unit: OPD Orthopedic

Address: Cubao, Q.C. department
Sex: Female Rehab Doctor: Dr. JP
Age: 50 Date of consultation: August 3, 2017
Civil Status: Married Date of Referral: August 5, 2017
Handedness: (R) Date of I.E: August 5, 2017
Occupation: Chef Diagnosis: (L) Shoulder Adhesive
Religion: Catholic Capsulitis
Referring Doctor: Dr. E.M.

HPI
Condition started ~5MOS PTIE when the pt experienced intermittent dull aching pain
(PS 6/10) on (L) shoulder while she was hanging clothes, pt disregarded the pain and
continued on c her daily activities. ~2MOS PTIE pt tried to reach for a high cabinet and
failed to do so d/t motion restriction & pain (dull, aching PS 8/10) pt tried taking
medications & asked her son for a massage on several occasions to relieve pain.

2 days PTIE pt consulted Dr. E.M. when earlier on the same day pt felt a constant dull
aching pain (PS 9/10) when trying to put jacket before going out. The physician tested
the pt’s shoulder motion and found that pain occurs during strongly during sh ER and
abd. The physician ordered for an imaging which revealed the pt’s diagnosis of
adhesive capsulitis. The pt then returned on the current day for a follow up appointment
c Dr. E.M., pt noted that the pain had lessened (constant dull aching PS 8/10) upon eval
the Dr. then referred the pt to rehab for further eval and tx.

Ancillary Procedure Date of Procedure Result

X-Ray August 3, 2017 (-) Fx

Medication Dosage Result

Unrecalled N/A N/A
Insulin 35 Units x od Increase insulin & glucose
regulation

S
PMHx:
(+) Controlled DM
(-) Hx of trauma
(-) Hx of previous operations
(-) Hx of neurologic conditions

FMHx:
FATHER MOTHER
DM (+) (+)
 CVA (-) (-)
Htn (-) (-)
TB (-) (-)

PSEHx:
Pt lives in a 2 story house with her husband and 2 kids
Type B
(-) Alcoholic Beverage Drinker
(-) Smoker
Regular Diet
Travels by car driven by husband
Hobbies: Tailoring, Gardening

C/C:
“Sumasakit ang kaliwang balikat ko kapag inaangat ko ang braso ko.”

PT Translation:
Pt experiences pain on (L) Sh whenever she raises her arm

O
VS:
BP 120/80 mmHg
PR 90 BPM
RR 18 CPM
Temperature 36.8˚ C

Findings: Vital signs are WNL

Significance:

OI:
 A/C/C  (+) swelling
 Ectomorph  (-) attachments
 (+) Postural Deviation  (-) deformity
 (+) pain distress  (-) Trophic changes
 (+) gait deviation  (-) erythema

Palpation:
Normotonic on all exposed parts
Normothermic on all exposed parts
(+) MM guarding towards abd, ER, Sh Flexion.
(+) MM Spasm on (L) trapezius
(+) MM Tightness of (L) Sh
(-) Tenderness
(-) edema
(-) effusion
(-) crepitus
(-) subluxation

ROM:
All major jts are WNL actively & passively done s pain & c (N) end feels except:

Motion A P N A(-) P(-) End feel

L Sh Flex 0-110 0-120 0-180 70 60 empty
L Sh Abd 0-90 0-100 0-180 90 80 empty
L Sh ER 0-30 0-60 0-90 60 30 empty
L Sh IR 0-35 0-50 0-70 35 20 empty

Findings: LOM at (L) sh

Increments during AROM ranges from 35-90˚
Increments during PROM ranges from 20-80˚
Significance LOM 2˚ to pain

MMT: Break Test was used during examination

All major ms are graded 5/5 except:
Sh Abd 4/5
Sh ER 4/5
Sh IR 4/5
Sh Fwrd Flex 4/5

Findings: mm are graded good

Significance: mm weakness 2° disuse

Grip Strength:

Special Test
Test Findings Significance
Appley’s Scratch Test Inability to reach middle LOM 2˚ pain
portion of back
Crank Test Complete stability of (-) for Anterior Shoulder
shoulder Instability
Clunk Test No clunk or grinding sound (-) for Labral Tear

Postural Analysis:
Postural Analysis is within normal parameters except for:
Posture Comment
Head Forward
Thoracic Kyphosis Increased

Findings: forward movement of head and increased thoracic kyphosis

Significance: Kyphotic Posture

Gait Analysis: Unremarkable

FIM
ADL:
w/c <-> Bed 7
Self Care
Eating 7 Locomotion
Grooming 7 Ambulation 7
Bathing 6 Stairs 7
Dressing: UE 5
LE 7 Communication
Toileting 7 Expression 7
Comprehension 7
Sphincter
Bladder 6 Social Cognition
Bowel 6 Social Interaction 7
Problem Solving 7
Transfer Memory 7
Bed <-> w/c 7

7 Complete independence
6 Modified independence
5 supervision modified independence
4 min assist modified independence
3 mod assist modified independence
2 max assist modified independence
1 complete dependence

Findings: ADLs for self-care are graded 7 except for grooming graded 5, bathing and
dressing UE graded 4
Significance: difficulty d/t pain and restriction of movement.

A
PT impression:
Pt has LOM 2˚ pain and restriction, MM spasm on (L) trapezium, Kyphotic posture
Rehab Potential: Good

Problem List:
1.) Pain (PS 8/10) upon sh ER, IR, ABD, Forward Flexion
2.) MM spasm on (L) Trapezium
3.) Limited ROM upon sh movement
4.) Kyphotic Posture
5.) Difficulty in ADL for self-care
6.) MM weakness
7.) gait deviation
8.) MM guarding

STG: 2-4Tx
1.) Decrease Pain on movement towards sh ER, IR, ABD, Flexion from (PS 8/10) to (PS
5/10)
2.) Decrease Spasm on (L) Trapezium
3.) Improve ROM towards sh ER, IR, ABD, Flexion
4.) To re-educate pt in proper body positioning
5.) To improve ADL for self-care from grades 5 to 7
6.) To improve mm strength from grade 4 to grade 5
7.) To re-educate pt in proper gait
8.) To reduce mm guarding on (L) sh

LTG: 5-10 Tx
1.) To achieve complete elimination of pain
2.) To achieve complete elimination of mm spasm
3.) To return ROM to (N) Limits
4.) To maintain proper body positioning
5.) To return pt’s ADL for self care to (N)
6.) To return mm strength to (N)
7.) To maintain proper gait
8.) To achieve complete elimination of mm guarding

P
Pt will be seen 2x/wk for 1mos

PT Mx:
1.) HMP + TENS on (L) Sh x20mins
2.) Ultrasound on (L) Sh x3.5MHz x5mins
3.) ROM Ex on A/P x10reps x3sets
4.) PJM
5.) Codman’s Ex x10reps x5sets
6.) Postural Retraining

Home Instructions:
1.) Use foot stool when reaching for high objects
2.) Do exercises taught by PT
3.) Avoid strenuous activities

Vincent Sebastian R. De Castro

PT intern/Perpetual help college of manila

Em Erald A. Domingo
PT intern/Perpetual help college of manila