Case 3: Jalea, Moreno, Ramos

CASE 3
JALEA, MORENO, RAMOS

Name: J.M.T.
Age: 48 y/o
Sex: F
Marital status: Married
Address: Batangas
Handedness: Right
Informant/Reliability: patient/good
Date of admission: August 2018
Referring Physician/Physiatrist: Dr. K
Date of Evaluation: February 2019
Type of patient: Out-patient
Dx: Left CVA
C/c: Difficulty in using her upper right extremity for
activities of daily living such as combing hair, showering,
and eating brought about by pain on the (R) upper
extremity
HPI
Premorbid status
Patient was independent in all aspects of ADLS as
to self-care (grooming, dressing, bathing, and
eating) and IADLS such as household chores
(washing dishes, cleaning the house, cooking,
washing clothes).
6 months PTIE
Patient suffered from (L) CVA and was admitted to
the ICU due to loss of consciousness. Patient was
discharged after 3 days. No ancillary procedures
were done. Pt was scheduled for a follow-up check
with her physician but pt did not attend this check
up.
4 months PTIE
Patient reported sudden onset of intermittent, diffuse
pain on the anterior aspect of her (R) shoulder (VRS 5/10)
which then pain radiated down to her entire (R) UE. Pt
reported pain on al motions involving the (R) UE. Pt
stated that pain was relieved with rest and pain
medications prescribed by her physician, and aggravated
by heat.
2 weeks PTIE
Patient reported that the pain on her (R) upper extremity
became constant and was increased (VRS 9/10). Patient
experienced pain in all motions involving the (R) UE. Pt
stated that the pain was no unrelieved by rest and
medication, which led to her apprehension in using the
said extremity. Due to this, pt also reports feeling
weakness in her (R) UE. Pt reported intermittent warmth
and swelling, and difficulty in gripping in her (R) hand.
1 Week ago
Patient reported onset of pain (VRS 6/10) on her (L)
UE in addition to her symptoms in the (R) UE. (B)
UE pain are unrelieved by rest and medications,
which limits her activity. Patient experiences
difficulty in performing household chores d/t pain.
Pt also reported difficulty in sleeping d/t pain.
At present
Patient is experiencing constant, diffuse pain on her
(R) UE (VRS 9/10) and (L) UE (VRS 6/10). Patient
experiences difficulty in performing household
chores and BADLs such as self-care d/t pain.
Medications:
Medication Indication Dosage and Frequency
Unrecalled Pain reliever As needed
Ancillary Procedures
• None
PMHx
• (+) Hypertension (uncontrolled)
• (-) RA/OA
• (-) Trauma/Injury
FMHx
Condition Maternal Paternal
HPN + +
RA/OA - -
PSEHx
• No Vices (Smoking, alcohol)
• Usually performs household activities such as washing
dishes, cleaning the house, cooking, and washing clothes
• Husband is the breadwinner of the family
• Has 2 sons that is both currently studying in college and
both lives in dormitories
• Cabinets in the house are within shoulder level
• Likes to perform gardening
• Usual diet includes fish, vegetables, and fruits
• Usual sleeping position: supine/(L) side lying
• Has sleep disturbances
• Patient has a driver that helps her go to Clinic
• Not knowledgeable about the condition
• In apparent pain distress
PHYSICAL EXAMINATION
Vital Signs:
A P
BP (130/90 baseline) 110/70 To Follow
PR 60 To follow
Temperature Afebrile Afebrile
Interpretation: All are WNL, except BP which is

below the normal value
Significance: for baseline purposes and treatment
precautions
OI:
• Ambulatory s AD
• No facial dropping noted
Extremities
• Normothermic
• (+) Mild drooping of (R) shoulder along with bilateral
prominence of the inferior angle of the scapula
• (+) swelling on (R) hand with mild erythema
• (+) flattening of the round contour of (R) deltoid muscle
• (-) trophic skin changes
•
Interpretation: Pt has mild drooping of (R) shoulder and
decrease in muscle bulk size of the ® deltoid muscle,
possibly indication anterior dislocation of GH
joint/paralysis of deltoid mm.
Significance: Pt may be experiencing difficulty in motions of
the UE d/t stated deformities, in addition to pain.
Additional tests may be done for confirmation of
suspected pathologies
Palpation:
• (+) palpable 1 fingerbreadth wide gap between (R)
acromion and humeral head
• (+) non-pitting edema of (R) hand c mild erythema
• Grade 3 tenderness on (R) humeral head region
• Hyperthermia on (B) hands
Interpretation: Pt has (+) sulcus deformity on ®
shoulder, possible indication of multidirectional
instability of GH joint or loss of muscle control d/t
stroke, and swelling on ® hand with tenderness on
® UE, possible indication of shoulder-hand
syndrome
Significance: Precaution during treatment, and
treatment specifications in order to address
suspected pathologies and presence of edema
Movement Analysis
• Right upper limb was not assessed d/t pain
PS 1-3 = +
PS 4-6 = ++
PS 7-10 = +++
Interpretation: Patient experiences pain during active

motions of (L) shoulder flexion at midrange (5/10),
extension at end range (4/10), abduction at midrange
(4/10), IR at midrange (4/10), and ER at end range
(4/10). During resisted motions of (L) shoulder flexion
at midrange (5/10), extension at midrange (4/10), (L)
elbow flexion at midrange (2/10), extension at
midrange (2/10), (L) wrist extension at midrange
(2/10). flexion at midrange (2/10), possibly indicating
affectation of contractile structures.
Significance: To assist in ruling in and ruling out
conditions, as well as for treatment specifications
ROM: AROM and PROM of the (R) upper limb was not done
due to severity of pain and discomfort of patient.
All other major joint motions are actively tested and are
WNL and pain free, except active motions in (L) UE which
are WNL but c pain
All other major joint motions are passively tested and are
WNL and pain free.
Interpretation: Patient has no LOM in (L) UE, but

experiences pain on motions of (B) UE in active motion,
and in passive motion of (R) UE
Significance: Pt will have difficulty in performing ADLs
involving the use of the UE d/t pain
Grip Strength
*Using 20 mmHg BP Cuff
Right Left Difference
Trial 1 N/A 60 mmHg N/A
Interpretation: Patient right hand cannot be

assessed due to pain
Significance: For baseline purposes
Anthropometric Measurements
Figure-of-8 Measurement:
Left Hand 39.1 cm
Right Hand 48.9 cm
Difference 9.8 cm
Interpretation: Pt presents with edema of (R) hand,

possible indication of shoulder hand syndrome
Significance: Pt may experience increased difficulty in
ADLs which involves the use of (R) hand. For
treatment specifications and home instructions.
Neurologic Examination
Mental Status:
• Alert, coherent, and cooperative
• Oriented to time, place, and person
• MMSE score: 27/30
Interpretation: Pt has no affectation in terms of

cognition
Significance: Pt has good reliability. Pt can also
understand and comply to exercises
Motor Evaluation
Tone Assessment:
Using Modified Ashworth Scale
• (R) UE was not assessed d/t severe pain

• (L) UE was normotonic
Interpretation: Pt did not want affected UE to be

moved, therefore, tone was not assessed d/t
severe pain on (R) UE.
Significance: Further testing is needed when pain
is decreased or absent
Sensory Assessment:
Superficial (Dermatomal)
STDs used: Sharp end of neurohammer for pain, and
brush for light touch
All dermatomal supply in the (L) UE were graded

normal.
Severe pain as to pinprick, light touch, and pressure in
entire (R) UE
Interpretation: Patient experiences hypersensitivity in

the (R) UE as to pinprick, light touch, pressure,
possibly indicating nerve affectations
Significance: Treatment specifications and
precautions
Deep
(R) UE was not assessed d/t severe pain and
discomfort of pt
Test Procedure (R) (L)
Proprioception PT asked the pt to close eyes and determine if the N/A 10/10
fingers or toes are positioned “up” or “down”
Kinesthesia PT asked the pt to close eyes and determine if the N/A 10/10
fingers or toes are “moving up” or “moving down”
Interpretation: Pt did not want affected UE to be

moved, therefore, proprioception and
kinesthesia was not assessed d/t severe pain on
(R) UE.
Significance: Further testing is needed when pain
is decreased or absent
Reflex Testing
(R) UE was not assessed d/t severe pain and discomfort of pt
DTRS:
• Interpretation: Patient has normal reflex on the Left

extremity; Pt did not want affected UE to be moved,
therefore, proprioception and kinesthesia was not assessed
d/t severe pain on (R) UE.
• Significance: Further testing is needed when pain is
decreased or absent
ADL Analysis:
Using DASH (Disabilities of the Arm, Shoulder, and Hand)
Outcome Measure
• Score of 96.6
Interpretation: DASH score indicates very severe difficulty

in the performance of ADLs, or possible symptom
magnification by patient
Significance: Patient’s symptom is severely debilitating
for the pt, causing severe difficulty in performing ADLs
ADLs Description
Bed mobility Pt is unable to side-lie on ® side d/t pain. Patient

avoids lying on affected side during sleeping, and
maintains supine position when lying down.
Transfers (Supine in bed to long From supine position, pt uses (L) hand on EOB and
sitting to short sitting) lifts trunk upward to position herself in long sitting
position Pt used her (L) hand to position herself in
short sitting on edge of bed. Pt does not use her (R)
hand all throughout the activity d/t pain
Bathing Pt is independent but only uses her (L) hand in

applying shampoo, soap, and rinsing her body.
UE/LE dressing Pt needs 1 man assist in UE/LE dressing. Pt mainly

only uses her (L) UE in putting on her clothes and
does not move her (R) UE d/t pain
Household chores Pt needs 1 man assist in performing household

chores such as washing the dishes, cleaning the
house, cooking, and washing clothes. Pt only uses
her (L) UE in all activities d/t pain in (R) UE in all
motions
Interpretation: Pt is able to perform her ADLs
independently but with difficulty and pain, and
requires 1 man assist during UE/LE dressing and
household chores. Patient also uses (L) UE during ADLs
Significance: Pt may experience increase in pain in the (L)
UE d/t overuse of the (L) UE.
PT Impression:
• Patient has severe difficulty in performing her ADLs as to self-

care such as combing her hair, showering and eating, and
performing her role as a housewife in performing household
chores which includes washing the dishes, cleaning the house,
cooking and washing clothes due to difficulty in moving (B) UE
in all motions brought about by impaired sensation as
manifested by hypersensitivity of (R) UE, impaired skin integrity
as manifested by non-pitting edema in (R) hand, associated with
APTA pattern 4D and 7B, secondary to possible shoulder hand
syndrome, secondary to (L) CVA
• Findings such as hypersensitivity of (R) UE, non pitting edema of

(R) hand, and pain during all motions support possible condition
of shoulder hand syndrome. Other findings such as presence of
sulcus sign on (R) shoulder and decrease in size of deltoid
muscle supports possible indication of instability of GH joint.
Clinical Impression
• Patient was previously diagnosed with (L) CVA 6 months

prior to initial evaluation. The patient’s clinical presentation
includes hyperalgesia and allodynia on (R) UE and non-
pitting edema on (R) hand. Furthermore, patient also
presents with (+) sulcus sign and decrease contour of
deltoid muscle, indicating GH subluxation. All these
manifestation are congruent with our working diagnosis of
shoulder hand syndrome.
Participation goal:
• Patient will be able to perform her role as a housewife
using (B) her UE without difficulty and pain within 3
months.
Impairment goal
• Pt will report decreased pain in her (R) UE from VRS 9/10 to
VRS 5/10 after 10 tx sessions
• Pt will present with decreased edema on her (R) hand from
9.8cm difference to 4cm difference after 5 tx sessions
Functional goal
• Pt will present with decreased difficulty in ADL
performance as manifested by improvement in DASH score
from 96.6 to 40% after 20 tx sessions

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CASE 3

JALEA, MORENO, RAMOS

Unrecalled Pain reliever As needed

Condition Maternal Paternal

BP (130/90 baseline) 110/70 To Follow

Temperature Afebrile Afebrile

Interpretation: All are WNL, except BP which is

Interpretation: Patient experiences pain during active

Interpretation: Patient has no LOM in (L) UE, but

Trial 1 N/A 60 mmHg N/A

Trial 2 N/A 60 mmHg N/A

Trial 3 N/A 60 mmHg N/A

Interpretation: Patient right hand cannot be

Left Hand 39.1 cm

Right Hand 48.9 cm

Interpretation: Pt presents with edema of (R) hand,

Interpretation: Pt has no affectation in terms of

• (R) UE was not assessed d/t severe pain

Interpretation: Pt did not want affected UE to be

All dermatomal supply in the (L) UE were graded

Interpretation: Patient experiences hypersensitivity in

Interpretation: Pt did not want affected UE to be

• Interpretation: Patient has normal reflex on the Left

Interpretation: DASH score indicates very severe difficulty

Bed mobility Pt is unable to side-lie on ® side d/t pain. Patient

Bathing Pt is independent but only uses her (L) hand in

UE/LE dressing Pt needs 1 man assist in UE/LE dressing. Pt mainly

Household chores Pt needs 1 man assist in performing household

• Patient has severe difficulty in performing her ADLs as to self-

• Findings such as hypersensitivity of (R) UE, non pitting edema of

• Patient was previously diagnosed with (L) CVA 6 months

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