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Patient Management Framework Written Case Presentation

Patient Management Framework Written Case Presentation. Matt Anderson DPT, OCS, CSCS 10/22/12 Upper extremity. Rationale for choice of case.

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Patient Management Framework Written Case Presentation

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  1. Patient Management Framework Written Case Presentation Matt Anderson DPT, OCS, CSCS 10/22/12 Upper extremity

  2. Rationale for choice of case • I chose this case because it shows my bias towards the cervical spine, in any problem related to the upper extremity. I found that I could not reproduce the patient’s symptoms using tests for my 1st hypothesis, so I had to continue questioning and testing.

  3. Patient Profile • Patient Profile: 58 y/o AAM. He is a former painter. He is now disabled (I could not get a good description of exactly how/why he obtained this status). Served in the US Army in Vietnam. • Chief Complaint: 1 month of constant, achy, swollen pain in the arm. The pain is present with movement. He is having trouble with eating, washing his face, and lawnmowing. He also reports hand weakness (he is R handed); Currently 7/10 achy pain from lateral lower upper arm to just proximal to the radial styloid

  4. Body Diagram Primary Complaint: Pt reports, “constant, achy, swollen pain”, which increases with movement (there are periods with no pain); located at lateral R arm-proximal and distal to the lateral elbow P1

  5. Exam Planning

  6. Hypotheses

  7. Symptom Behavior • Aggravating and Easing Factors: • Repetitive motion for eating (during meal, progressively increases to 7/10, takes ~20 minutes to return to baseline of 0-2/10 with rest) • Washing his face (Diffuse pain at the lateral elbow ~3 inches above and below- up to 4-5/10, takes ~15 minutes to return to baseline of 0-2/10) • Lawnmowing x 20 minutes brings pain up to 7/10, takes ~15 minutes to return to baseline of 0-2/10, he is able to do this 4 times to mow his whole yard • Pain never goes above a 7/10, and he reports that it does not seem to spread to any more areas other than what was initially described. Rest at any time of the day reduces the pain to 0-2/10 after ~15 to 20 minutes

  8. History • Sleep and 24 hour pattern: • Sleep: Intermittently wakes up due to arm pain (average 2-3 times per night)- change position and fall back asleep in <10 minutes • Morning: Feels good (0/10- upon waking) • Day: Pain varies from 0/10 to 7/10 depending on activity • Duration of current symptoms: 4 weeks • Mechanism of injury / current history: The patient reports 1 month of constant, achy, swollen pain in the lateral arm and forearm. He currently has pain with eating, washing his face, and lawn mowing. No known injury, and cannot recall specific onset. • Numbness/Tingling: recent h/o hand numbness (started ~4 months ago and lasted ~2 months, with medication complete relief- he no longer takes the med- anti-inflammatory)

  9. Patient Intake • Medical History/Co-morbidities: • h/o LBP, h/o chest pain, DDD cx and lx, Peripheral nerve disease, h/o tobacco use, hemorrhoids, asthma, anemia, h/o blurred vision, HTN, colon carcinoma • Special questions: • CBC WNL, oncology yearly appointment in June 2012- all clear, Cardiology follow up in May 2012- all clear • Yellow flag screen: • 2 question depression screen – • H/o PTSD • Red flag screen: • No change in b/b, no current blurred vision (dx as vestibular problem), no gait abnormality, no unexplained weight loss, no present complaint of numbness/ tingling, no chest pain, SOB- asthma related w/ exertion, no falls/drop attacks

  10. Subjective Asterisks • Pain/ difficulty with eating (bringing food to his mouth repetitively) • Washing his face (Diffuse pain reported at the lateral elbow and ~3 inches above and below at 4-5/10) • Lawnmowing (pain increased to ~5/10 after mowing for 10 minutes)

  11. Hypotheses (revised #1)

  12. SINSS • Severity: Moderate- Difficult to eat and wash face, but he still does all activities he needs to do; Pain level reaches 7/10 during the day • Irritability: Moderate- Pain with movement, off quickly with rest, wakes him up at night due to aching • Nature: Cervical component vs TOS vs Lateral epicondylalgia • Stage:Subacute • Stability: Staying the same

  13. Planning the Objective Exam • At this point I expected the root of the problem to be in the cervical spine. I planned to start my OE there: • -Neuro screen • -Cervical Radiculopathy TIC • -TOS special tests • -Prone C-spine palpation and PAIVM • -Upper Limb Tension Test- Radial nerve • -Further UE exam, if needed

  14. Objective Exam • Here is what I found: • Neuro screen: DTR 2+ tricep, bicep, BR; - Hoffman’s, MMT-no weakness; Grip strength significant weakness in R grip at position II and III (80# difference compared to L), Slump: - • Cx ROM: Flexion 80%, pt reports pull in low back- no familiar symptoms Extension: 70%, no pain or symptoms produced Rotation: WNL B, no pain produced SB: L WNL, R 35 degrees, pulling felt on L side CxRadic TIC: Spurling’s – Distraction – ULTTA – Neck rotation – Cx PAIVM: Stiffness present with Grade III pressure CPA and R UPA (L UPA good motion, no pain)- no pain produced; caudal, cephalad, medial and lateral biased pressures produced no pain or reproduction of symptoms, but were slightly stiff Palpation of scalenes, pec minor and 1st rib: no pain and he tolerated Grade IV pressure at rib

  15. Objective Exam • CRLF Test: negative bilateral • Upper Limb Tension Test- bias for Radial Nerve: full motion with end range sharp pull bilateral • At this point I had ~15 minutes left, and did not feel like I had chosen the right hypothesis. The c-spine was not adding up. I then focused on the upper extremity

  16. Objective Exam • Palpation: R lateral epicondyle TTP w/ wincing (bony prominence, extensor tendon, extensor muscle belly) • - at this time I thought about our recent discussions about using treatment to confirm/rule out a hypothesis • Needle palpation of wrist extensors and tricep (lateral head) produced twitch with familiar pain produced • Achiness present, but grip strength improved by 25# at level II, and 35# at level III after TDN intervention at these areas • Radial head mobility: Grade II P/A and A/P produced familiar pain- • Manipulation of radial head produced reduction of pain w/ hand to face movement pattern from 7/10 to 3/10 • Wrist ROM:Flexion: WNL, Extension: 35 degrees on R • Hypertrophy observed at wrist flexors and extensors

  17. Assessment and Plan

  18. Day 1 Treatment

  19. Day 1- Response to treatment and planning for future visits • Other treatment provided today and the patient’s response: • Exercise: 1. Wrist flexor and wrist extensor stretches; 3x30 seconds each; elbow flexed and elbow extended; 2. Wrist extension self-mobilization on table- 3x10 daily • Education: discussed painting career, and repetitive motion contribution to the problem • What changes did you note in your asterisks (test/retest)? • Reduction in pain (7/10 to 3-4/10), Improvement in R wrist extension by ~15 degrees; Grip strength changes of 25-35# • Prognosis (note timeframe of expected level of recovery): • The patient had a good response to treatment, and was really motivated to improve his arm pain and function. He has a good prognosis. • Plan of care (including plan for assessment on day 2): • Better: Repeat radial head manipulation and dry needling to the area (seeing pt 1x/week), add eccentric exercises for wrist extensors • Worse: Assess and treat other elbow joint structures • Same: continue day 1 treatment, add mobilization with movement technique

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