Tiêu đề SOAP NOTE - ADHESIVE CAPSULITIS - SEM 1 - FELLIZAR ✅

Republic of the Philippines Lapu-Lapu Cebu International College College of Physical Therapy Ticgahon 1 Road, Bankal, Lapu-Lapu City SEMINAR 1 - SHOULDER CONDITIONS ADHESIVE CAPSULITIS PT SOAP NOTE Submitted by: Fellizar, Andei Paula Y. BSPT - 3B Submitted to: Odette Justo, PTRP, MRS August 2024 1
SOAP NOTE “ADHESIVE CAPSULITIS” CASE STUDY I. SUBJECTIVE A. General Information: 1. Patient’s Name: A. N. M. 2. Age: 41 Rationale: Adhesive capsulitis (AC) is often diagnosed in individuals between the ages of 40 and 59, but also occurs among older adults (Jacob et al., 2023). 3. Sex: F Rationale: Females have higher risk for AC than males, which may be attributable to physiological and psychological factors, such as estrogen hormones, which has a “pro-inflammatory effect,” making women prone to experiencing pain (Abudula et al., 2024) 4. Address: California (Filipino-Immigrant) Rationale: Asian ethnicity is a risk factor for developing AC (Malavolta et al., 2018). 5. Civil Status: Married Rationale: A study by Chen et al. (2022) found that married workers experience more stress than other “marital status,” which increases their risk of developing shoulder pain. 6. Handedness: Right-Handed Rationale: The non-dominant hand is usually affected in AC (Dolas & Sarkar, 2023), as such is found in a study conducted by Anjum et al. (2020) where patients who are right-handed have left shoulder AC. 7. Occupation: Accountant Rationale: Females with chronic pain, such as in the neck and shoulder, are often doing repetitive tasks in the same posture at work, household chores, or during childcare (Lee & Oh, 2022). 8. Referring Unit: Orthopedic Unit 9. Dx: > (L) Rotator cuff capsule sprain and strain B. C/C: ● (L) shoulder mobility loss C. Patient's Goal: ● Pt. wants to regain full shoulder motion, perform independent ADLs and return to swimming and yoga D. HPI: 2
Present conditions started ~7 months ago prior to PT IE, when the pt. felt a “jerking pain” in her (L) shoulder as she attempted to pull a heavy box on the ground. Immediately after this incident, she experienced swelling and severe pain at the anterior aspect of the affected shoulder. While swelling resolved after 2 weeks, high pain levels with movement in the area surrounding the (L) shoulder jt. persisted and the pt. admitted experiencing pain with light touch to the area. Pt. reported using a sling to immobilize the shoulder for a month to avoid pain and re-injury, which is only removed when bathing, dressing, and sleeping. Since the incident, pt. pain intensity had substantially decreased while loss of shoulder mobility persisted. Pt. was unable to provide specific information about the active movements which aggravated sharp and moderately intense (L) shoulder pain, but admitted that pain eased immediately when getting out of the aggravating position or ceasing the aggravating movement. Pt. was unable to provide further easing factors. Pain described as a “weak tightness” was associated with lower pain intensity and would occur when the pt. attempted to use her left UE to unfasten her bra, and reach above the level of her shoulder such as to shave the left underarm or tie her hair in a ponytail. (L) shoulder mobility loss also prevented her from participating in swimming and yoga for exercise. Pt. productivity at work as an accountant was reportedly unaffected at the time of initial evaluation. The patient reported her preference for conservative management of her limitations and was apprehensive about the possible need for surgical intervention. E. Ancillary Procedures Procedure Date Result X-ray (Anteroposterior View) Not stated Degenerative changes in the glenohumeral jt. Rationale: Although radiography can help rule out other shoulder pathology, specifically those involving the bone, it is not as effective and helpful as MRI in determining shoulder capsule pathology as soft tissue would not be visible (Vita et al., 2024; Ramirez et al., 2019). F. Medications: Drug/Medication Name Dosage Frequency Indication Side Effects Route Advil (Ibuprofen) 200 mg, prn Not stated Pain constipation, diarrhea, gas or bloating, dizziness, nervousness, ringing in the ears, unexplained weight gain, shortness of breath or difficulty breathing, swelling of the abdomen, feet/ankles/ legs, fever, blisters, rash, itching, hives, swelling of the Oral 3
eyes/face/throat/arms/hands, difficulty breathing or swallowing, hoarseness, excessive tiredness, pain in the upper right part of the stomach, nausea, loss of appetite, yellowing of the skin or eyes, flu like symptoms, pale skin, fast heartbeat, cloudy/discolored/bloody urine, back pain, difficult or painful urination, vision problems, red or painful eyes, stiff neck, headache, confusion, aggression Rationale: NSAIDS are the usual treatment options for AC since, although it does not change the course of AC, it allows patients to participate in PT and perform ADLs pain free or with less pain (Pandey & Madi, 2021). G. PMH: (-) Cancer (-) Thyroid disorder (-) Diabetes Mellitus (DM) Rationale: Despite data from previous studies, breast cancer has no significant association with AC, but shoulder function of breast cancer survivors must still be regularly assessed (Jacob et al., 2023). Individuals with thyroid diseases, especially those with hypothyroidism have higher risk of developing AC compared to those without (Chuang et al., 2023). A systematic review and meta-analysis conducted by Dyet et al. (2023) had also found that DM is highly associated with the development of AC due to factors such as chronic inflammation and capsular fibrosis present in DM. H. FMH Maternal Paternal Osteoarthritis (OA) (-) (-) Adhesive Capsulitis (-) (-) DM (-) (-) Dupuytren’s disease (-) (-) Rationale: OA is a major risk factor for developing AC, and is often heritable (Jacob et al., 2023; Wilkinson & Zeggini, 2021). Furthermore, a family history of AC, especially from a first-degree relative, also increases the likelihood of developing this condition (Dolas & Sarkar, 2023, Sumarwoto et al., 2021). Although environmental factors can influence the development of DM, which can be the cause of secondary AC, it is a 4