SECTION OF PHYSICAL THERAPY

DEPARTMENT OF REHABILITATION MEDICINE

UNIVERSITY OF THE PHILIPPINES-MANILA
CN: 4215155
Jamera, Perlita
Dx: CTS; S/p carpal tunnel release (12/15). OA L knee
DOR: January 19. 2016
RIC: Constantino
Precautions: Burn precaution
Initial Evaluation: January 20, 2016

S:
C/c: Pt c/o “pangingimay” and tingling sensation on her ® hand whenever she does activities which requires the use of her hand. Also pt c/o inability to pick up
small objects and difficulty in grasping a glass of water.
Goals: Pt wants to be able to pick up small objects and be able to grasp a glass of water. Also she wants the “pangnigimay” to be lessened also c tingling
sensation on her hand.

HPI:
Present condition started last June 2015 when pt experiences falling of the needle from her ® hand whenever she sews her clothes and she felt that
the butt end of the needle feels painful whenever she push it through her fingertips. Also when she opens their sliding door her fingertips feels pain upon
pressure on it. Also pt cannot squeeze or rub the clothed between her hands whenever she wash their clothes.
July 2015, pt went to consult a MD at Binan doctor’s d/t worsening of her ® hand. She feel numbness and increase tingling sensation on her hands
and she noticed a slight deformity on her hand (ape hand deformity). So the MD examined her and advised her to undergo EMG-NCV and prescribed her to
have 3 PT sessions. So pt finished her 3 PT sessions and she felt slight relief but the pangingimay and tingling sensation comes back every after PT session. So
at the 2nd week of July, pt had her EMG-NCV and when the results came she was advised to undergo CTS release but the pt asked if it can be resolved c
undergoing PT session but the MD said it cannot be resolved anymore. The MD prescribed pt c Pregabalin. Pt still feels constant pangingimay and pt has
weakened grip strength on the R hand.
September 2015, pt went to seek another medical advice at PGH, she was examined and she showed the result of her EMG. And the Ortho MD
advised the pt undergo operation but first she needs clearance from her endocrinology for her thyroid problem. 2 nd week of September, pt underwent series of
laboratory exams and she was diagnosed to have hypothyroidism so she was prescribed c Euthyrox to for normalization. At 3rd week of September pt was
rushed to PGH d/t high blood pressure, she stayed there for 1 day and she was prescribed c Micardis for her HTN.
October 2015, pt underwent another series of lab exam and they found out that she has normal lvls of TSH which means her hypothyroidism was
normalized already. On that day she was scheduled for operation on December.
December 2015, she was operated and a day after she went home. She was able to cook and sweep the floor a day after the operation. 2nd week of
December she was back to her normal activities but except for washing clothes cause she doesn’t want to force it. Pt had her follow up check-up c her ortho this
January and she was advised to undergo PT session so she was referred to Rehab med and she was examined and referred here at PT rehab for further
evaluation and management.

PMHx:
(+) trauma at R forearm (1990’s)
(+) HTN (2015, controlled)
(+) asthma (unrecalled)
(+) thyroid problem (2007, controlled)
(-) DM
(-) cancer
(-) infection
(-) heart disease

FMHx:
Condition Maternal Paternal
HTN + +
Heart disease + -
Arthritis - -
DM - -
Cancer - -
Pulmonary disease - -

PSEHx:
Pt is R handed
Pt is currently unemployed she stopped working last 2011.
Pt is always at home doing household chores such as cleaning the house, washing clothes, washing the dishes, folding laundry, cooking and sewing clothes.
Pt lives in a 2-storey house c her husband and brother in law.
Pt’s room is in 2nd floor. Pt’stairs has 12 steps c half foot height of each steps. Pt’s stairs to CR is ~2 meters, ~ 5 meters to kitchen, ~3 meters to living room.
Pt’s house is equipped c doors who has a circular door knobs and their faucet requires pronated forearm and radial and ulnar deviation of the hand.
Pt has no vice and watches TV during her free time.

Ancillary Procedures:
Procedure Taken Result/s
EMG-NCV July 2015 at Binan doctor’s According to the pt the result was Severe carpal
tunnel syndrome and need for carpal tunnerl
release
Laboratory exams September 17, 2015 at PGH According to the pt, she has decreased thyroid
stimulating hormone level
Laboratory exams October 2015 at PGH According to the pt she has Normal TSH level
Present medications
Medication Dosage/Frequency Indication
Micardis 40 mg OD used to treat high blood pressure (hypertension)
Euthyrox 75 mg OD used to treat an underactive thyroid.
Metformin 750 mg OD oral diabetes medicine that helps control blood
sugar levels
Calcitrate Unrecalled used to prevent and to treat calcium deficiencies
WOF side effects such as: headache or muscle pain, feeling short of breath, even with mild exertion, increase urination, swelling hands/ankles/feet, seizures.

O:
Vital Signs: Before After

BP (mmHg) 130/80 130/90

PR (bpm) 83 89
O2 sat 98% 98%
Significance: pt has stable VS which clearly means that she can tolerate management given to her.

OI:
Mesomorph
Ambulatory s AD
(+) scar at R dorsal aspect of wrist (see scar assessment)
(+) slight ape hand deformity on R hand
(+) redness on dorsal aspect of R wrist
(-) swelling on R hand
(-) resting hand splint
(-) trophic skin change on R hand
(-) papal benedict deformity on R hand

Palpation
Normothermic on all exposed body parts
(+) tenderness on the surgical scar on dorsal aspect on the R wrist

Grip Assessment:

TRIAL (R) (L)

1 30 mmHg 80 mmHg
2 50 mmHg 80 mmHg
3 50 mmHg 75 mmHg
Average 43.33 mmHg 78.33 mmHg
Significance: Pt has significant decreased in grip strength on R hand may be d/t pt haven’t used it c enough force for a while and maybe d/t the operation.

Sensory Assessment:
Findings: Pt perceived decrease sensation on B hand on the palmar aspect of thumb to middle finger as to pain 40% 3/3 trials, pressure 30 % 3/3 trials and light
touch 70% 3/3 trials
Significance: This may be a precaution when applying modalities on pt’s hand. And pt may not feel what she is holding.

Scar Assessment:
Location: on dorsal aspect of R wrist
Length: 2.5 cm
Color: reddish
Mobility: hypomobile
Significance: Pt has hypomobile scar which may limit pt’s movement towards wrist extension.

ROM: all major joints of (B) UE were actively and passively taken and noted to be WNL and c normal pain free end-feel except for:
Motion Active Passive Difference from N Normal Value End-feel
R wrist extension 0-50o 0-65o 5o 0-70o Firm
L knee flexion 0-115o 0-120o 15 0-135o Soft
Significance: pt’s LOM on R wrist extension is d/t the restriction brought about the scar on her R dorsal aspect of wrist cause she feels stretch pain during
passive movement of it. While on the L knee flexion LOM it is d/t approximation of two bulky muscles of the pt.

MMT: all major muscle groups of (B) UE were grossly assessed and graded 5/5 except for:
Wrist extensor 4/5
Significance: Pt decreased in weakness may be d/t the operation and pt haven’t exerted too much force c her R hand for a while now.

ADL Assessment:
Pt is independent on all aspect of ADLs s any difficulty or modification except for:
Activity Current Performance
Cooking Pt has difficulty as to opening pots c small handle as manifested by difficulty to pinch it and falling the
object out from the pt’s hand.
Picking up objects Pt has difficulty to pick up small objects such as 25 cents, earrings and beads as manifested by
inability to perform tip pinch to pick up those objects and increased in time to perform the
activity.
 Grasping Pt has difficulty as to grasping glass of water as manifested by difficulty to perform cylinder grasp so pt
just perform spherical grasp when drinking also the glass should be supported by the L
hand.
Writing Pt has difficulty in performing three fingered pinch when holding the ballpen instead she uses tip pinch
to hold the ballpen.
Opening a door knob Pt has a difficulty of opening a door knob as manifested by over pronation of the forearm when opening
it.
Significance: Pt has difficulty as to gripping and grasping on R hand secondary to CTS release.

A:
PT impression: Pt has inability to pick up small objects using her R hand d/t feeling of pangingimay and numbness on pt’s hand when doing activities which
requires use of hand also c decrease sensation on R hand which may predispose pt to not feel what she is picking up.D/t pt’s release of carpal tunnel, pt
developed weakness and LOM towards wrist extension secondary to the presence of a hypomobile scar on pt’s dorsal aspect of R wrist and also pt hasn’t used
her R hand for too much force. Furthermore pt has difficulty as to grasping a glass of water secondary to weak grip strength of the R hand may be d/t the
operation and her condition.
Prognosis: Pt has good prognosis as to relearning her ability to pick small objects and be able to perform household chores s any difficulty and s any
modifications. Though pt presents decreased in grip strength, LOM on wrist extension, weakness of wrist extensors and decrease sensation brought about the
surgical operation this can be addressed through PT management. Also pt’s healing is still in subacute so there is a greater chance for better recovery because
pt underwent PT session early. Meanwhile presence of co-morbidities such as HTN, DM, thyroid problem and asthma may not complicate pt’s healing cuase
they are all controlled by medications. As to re-learning the different types of grip and pinch it can be taught and practice at home. Lastly, pt is willing to undergo
and adhere to PT mx given that will be given to her and she is motivated for her further recovery.

Problem List:
1. Difficulty in opening pots c small handle and pick up small objects as manifested by difficulty in pinching it and increased in performance time when
doing it.
2. Difficulty in grasping glass of water as manifested by using spherical grasp when doing the activity.
3. Difficulty as to opening of door knob as manifested by over pronation of forearm when doing the activity.
4. Decrease in grip strength of R
TRIAL (R) (L)
1 30 mmHg 80 mmHg
2 50 mmHg 80 mmHg
3 50 mmHg 75 mmHg
Average 43.33 mmHg 78.33 mmHg
5. Decreased in sensation of R hand
6. Feeling of pangingimay and numbness on pt’s hand when doing activities which requires use of hand
7. Weakness of R wrist extensor 4/5
8. LOM of the following motions:
Motion Active Passive Difference from N End-feel
R wrist extension 0-50o 0-65o 5o Firm
L knee flexion 0-115o 0-120o 15 Soft
9. Hypomobile scar
10. Tenderness at of the scar

Goals:
LTG1: Pt will go back to washing clothes c adequate grip strength to squeeze the clothes s any difficulty and pain for 6 weeks
LTG2: Pt will open a door knob s over pronation of forearm for 30 seconds s any difficulty and pain experienced after 5 weeks
LTG3: Pt will pick up 15 small objects with tip to tip prehension s falling of the objects from pt’s hand for 40 seconds after 5 weeks
LTG4: Pt will drink from a glass with cylindrical grip s help from L hand for 5 minutes after 5 weeks
STG1: Pt will have increase in ROM of wrist extension to 3 degree increment after 4 weeks
STG2: Pt will report decrease in pangingimay and numbness on R hand after 4 weeks

P:
Focus of the treatment is to increase pt’s grip strength also c the strength of her extensors and increase ROM of R hand together c practicing of prehension and
grips for her to be able to hold glass of water, pick up small objects and go back to her daily activities.

MD prescribed Mx:
1. TENS over B CT x 20 minutes
2. PWB on B hands to extend above the wrist
3. Stretching of wrist extensor and flexor
4. Strengthening of B quads, hams, gastrocs
5. LE ergometer
6. Tendon gliding techniques
7. Wall slides
PT plan:
1. TENS on R wrist x 15 minutes
2. PWB on R hand x 15 minutes
3. GPS of wrist extensors and flexors x 30sh x 3 reps
Progress to 5 reps
Progress to self-stretching
4. Partial squats x 10 reps x 3 sets
Progress to 5 sets
Progress c arms forward
5. Butt kicks x 10 reps x 3 sets
Progress to 5 sets
Progress c ankle weights
 6. Heel/toe raises x 10 reps x 3 sets
Progress to 5 sets
7. Bike x 15 minutes
8. Tendon gliding techniques x 6sh x 5 reps
Increase to 10 reps
Suggested PT Mx:
1. Respectfully not treating the L hand d/t pt doesn’t feel any pain on it and she has not complain about it
2. Respectfully suggesting the ff:
a. Towel curls x 5 rounds. To improve strength of the finger flexors and extensors
Increase to 10 rounds
Add ankle weights at the end
b. Grip strengthening c digiflex x 6sh x 10 reps. To increase grip strength
Increase to 15 reps
Change digiflex
c. Pinch exercise using the wax of the PWB x 10 reps x 3 sets each finger. To practice proper pinching
Increase to 5 sets
d. PRES of the wrist muscles using theraband x 10 reps x 3 sets. to strengthen wrist musculature
Increase to 5 sets
Change theraband
Home instructions
1. Immerse hands in comfortably warm water for 15 minutes. Make sure to check skin every 5 minutes to prevent burn precaution.
2. Do grip strengthening c a towel x 6sh x 10 reps
3. Do towel curls x 10 rounds
4. Practice picking up grain of rice. Transfer it from a bowl to another x 30 reps.

Recommendation:
1. Respectfully recommending pt to OT for further management as to hand skill of the pt.

FLOJO, DIANNA M.
MMSU PT INTERN ‘16