Day 1

Subjective: Mrs. X is a 46 year old female patient who just has surgery for the repair of multiple

shoulder injuries. Mrs. X’s surgery involved a completely detached biceps tendon, rotator cuff tear, and

sub-scapular release. The patient reported pain deep in the shoulder joint. She also reported the bicep,

elbow, and tricep are very stiff. Patient has been taking Advil for pain. She is married and has two

children. Pain rating = 6.

Objective: DASH: Symptom Total Score-82.5, DASH: Work Module Total Score-43.75, DASH: Sports/

Performing arts Module Total Score – 100.

Hypersensitive to palpitation (touch) in the right bicep, soft tissue tension in the R shoulder.

Patient was educated on the evaluation results and implications for treatment.

Assessment: Criteria for treatment has been met. The patient experiences several limitations including

work, self-care, leisure, body mechanics, and home management. Potential for rehabilitation – good due

to chronic nature of injuries.

Plan: Goals:

Independent with home exercise program.

Reach overhead and lift objects in and out of cabinets.

Independently put clothes on and off.

Reach top of head to perform self care routines.

Verbalize understanding of ergonomic concerns in the office setting.

Decrease DASH scores by 15.

Return to swimming without increase in pain or symptoms.