PTH 633 SOAP Note Template THERAPIST NAME: Cara Stewart

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ICD-10-CM Codes: M75.121, S43.431D

Patient Name: Julie Harris DOB: 07/06/1995

Date of Service: 02/09/2018

BACKGROUND INFORMATION:
Referral Source: Dr. Brandt
Referring Diagnosis: Full-thickness RCT of supraspinatus & Type II SLAP Lesion of R
shoulder
Treatment Requested: Evaluation & initiation of comprehensive rehabilitation program
Other Referral Information: 4 wks S/P arthroscopic repair

SUBJECTIVE:
History of current complaint: Pt is 22 y/o female who c/o R shoulder instability that
started 6 mo. ago. Describes pain post-surgery as dull, aching, and stiff and says R arm
feels “heavy and tired.” Rates pain at 4/10. Pt states that shoulder feels better when arm is
supported in sling or on pillow, and it feels worse when it is hanging by her side. Pt fell
and dislocated R shoulder, but had no prior PT.

Current Functional status/activity/participation level: Pt’s dominant arm is R. Pt is

unable to bathe, dress, or drive by herself. Pt has trouble with eating and states she is
unable to eat peas which “are my absolute favorite food.” Unable to carry backpack to
school so boyfriend carries it for her. Unable to play tennis. Difficulty sleeping since she
has been sleeping in a La-Z-Boy recliner. Parents and boyfriend are around to assist when
needed.

Prior level of function: Was able to complete all ADL’s with only minimal pain at times
due to shoulder instability. Was able to play tennis daily.

Medical/Surgical history; general health status: Pt has hypothyroidism. Non-smoker.

Occasionally drinks alcohol. Overall in good shape due to being tennis player.

Current medications: Took Vicodin for 1st 2 weeks post-op. Takes Ibuprofen BID.
Ibuprofen temporarily relieves pain.

Allergies: Bees. Carries EpiPen with her at all times.

Employment status: Pt is a current student at CMU. Is in class & tennis practice 5

days/wk from 8am-8pm. All classes are in one building with no stairs. Tennis courts are
PTH 633 SOAP Note Template THERAPIST NAME: Cara Stewart
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far away but boyfriend drives her to practice every day. Sits all day in class but stands
while watching tennis practice. Pt is on scholarship to help with funds of schooling.

Home/Work/Other Environment: Lives with mom and dad in 2 story house. Pt’s
bedroom & bathroom are on 2nd floor, but parents room is on 1st floor. Only tile and wood
flooring throughout house, no carpet. Campus is flat and no stairs to climb to get to class.
Tennis courts and surrounding area is also flat.

Family health history: None

Social/Cultural history: Primary language is English. No social or cultural preferences

that may affect care.

Patient goals: Pt wants to be able to play tennis again every day. Pt wants to be able to
bathe and dress herself. Also wants to be able to drive a car again to take herself to class
and tennis practice.

OBJECTIVE:
Systems Review:
Cardiovascular/Pulmonary: HR: 117/74. RR: 13 bpm. BP: 74 bpm.

Integumentary: 3 incisions on R shoulder (one ant, one post, one lat). Skin slightly red
around incision sites. Incisions mostly closed – no fluid leakage.

Musculoskeletal: Pt is mixture between ectomorph and mesomorph. PT was unable to

measure gross AROM due to current post-op status of pt.

Neuromuscular: Pt has typical movement pattern & gait. Coordination and balance are
intact.

Communication/Affect/Cognition: Pt is fully alert with no behavioral deficits.

Examination:
General Anthropometric Observations/Posture: Posture while seated and standing
consists of R shoulder rounded forward more than L. R shoulder also sits much lower
than L.

Inspection/Observation: Edema of R shoulder. 25cm on L and 32cm on R. Slight muscle

atrophy of R shoulder.

Neurological/Sensory: Light touch and sharp/dull WNL everywhere except diminished

axillary nerve sensation of R shoulder.
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ROM: All ROM measurements were done passively in the scapular pain. Pt was in high-
seated position with pillow under R shoulder for support. Pt helped give feedback on
where end-range was & then a goniometer was used to measure. Pt had slight pain at end-
range of all positions.
Motion R Shoulder L Shoulder
Flex 65 WNL
Abd 60 WNL
IR 44 WNL
ER 18 WNL
*Ext and horizontal add measurements were not taken due to Dr.’s restrictions

Muscle Length/Flexibility: Unable to test due to restrictions.

Strength/MMT: Unable to test due to restrictions.

Palpation: Tenderness around incision sites on R shoulder

Joint play assessment: N/A

Special Tests: Unable to test due to restrictions.

Gait: Normal rhythm and symmetry. No assistive device used.

Functional Mobility: Able to transfer independently to/from bed & chair. Unable to dress
or bathe. Unable to drive.

Balance: Intact while seated & standing.

Standardized Outcome Assessments: Shoulder Pain and Disability Index (see attached
sheet). Pt’s pain score is 48%, disability score is 56%, and total score is 53%. Pt has
moderately high score for disability, meaning she has difficulty performing many tasks
due to her injury. Pt’s pain score is also fairly high, indicating she has pain completing
tasks she never used to have pain with before.

INTERVENTIONS:
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PT received informed consent from pt to begin an exercise program. It was explained to

pt that treatment must begin at a low level of intensity since pt is still at the end of phase I
of recovery. It was explained that exercises will start as PROM/AAROM, and will
eventually progress to AROM and then RROM when pt is ready in the weeks to come.
The following exercises were performed by the pt today & PT explained to her that the
benefits of these exercises will be to increase ROM & strength of her R shoulder & arm.
The pt was also informed that a risk of going beyond the restrictions from the Dr. while
exercising could be a disruption of the healing process.
Pt received PROM by PT for flexion, ER, & IR in scapular plane. Pt’s mother was also at
the session & was instructed on proper technique of PROM exercises in order to assist
her daughter at home. 10 reps of each motion were completed and pt was instructed to do
this at home BID with assist. from mother. Next, pt was instructed on pendulum
exercises, using body to create motion & letting involved shoulder move along with body
movements. Pt was instructed to complete pendulums for 1 min increments QID. Pt then
completed 3 sets of 10 reps of scapular pinches & was instructed to perform these at
home BID. Pt was instructed to perform scapular pinches while sling is on or while R
arm is resting on pillow, in order to ensure pt does not let R shoulder go into extension
past neutral. Final exercise for the pt was ball squeezes with R hand to improve grip
strength. Pt performed 30 squeezes & was instructed to complete these at home TID. Pt
has recumbent bike at home & was instructed to ride for 30 min/day, 3 days/wk. Pt was
also instructed to walk around while watching at tennis practice to stay active, rather than
just standing & watching. Pt stated she currently uses ice at home & was instructed to
continue using ice at home prn. Pt was also instructed to keep arm supported under pillow
when not in sling. Pt responded well to all exercises & performed them with proper form.

ASSESSMENT:
PROBLEMS:
Body Structure/Function Alterations:
1. Unable to raise R arm above shoulder height (dec ROM)
2. Unable to fully externally & internally rotate R shoulder (dec ROM)
3. Pain of R shoulder
4. Muscle atrophy of R shoulder

Activity Limitations/Participation Restrictions:

1. Unable to drive to class and tennis practice
2. Unable to participate in tennis practice
3. Unable to bathe or get dressed independently in the morning
4. Unable to take notes during school with R hand
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Summary-Clinical Impressions: Pt’s injury has caused deficits in performing many

ADL’s. Her dec ROM and dec strength are interfering with her ability to participate in her
typical activities. Pt was seen at end of 4th wk/beginning of 5th wk, which would mean she
would be starting phase II. However, since she just started therapy, and is still under
restrictions from Dr., she is slightly behind and still in phase 1. However, she responded
well to the exercises given to her, so she should still be able to progress through phase I
quickly.

PT Diagnosis: Pain, dec ROM, and muscle atrophy of R shoulder.

Rehab Potential/Prognosis: Prognosis is good since pt was WNL on L shoulder, so she
has the potential to get her R shoulder back to a normal range as well. She responded well
to performing daily exercises, she just needs to stay on track and not engage in too much
active motion too early on.

GOALS:
Short-term (to be achieved in 4 weeks):
1. Pt will inc IR to 60 and ER to 40 to be able to get dressed and to drive independently
2. Pt will inc shoulder flex to 110 in order to reach above head & wash hair while
bathing
3. Pt will report dec pain to 2/10 in order to be more comfortable and fall asleep quicker

Long-term (to be achieved in 8 weeks):

1. Pt will inc gross strength and ROM so that her SPADI score improves to less than 30%
overall.
Long-term (to be achieved in 12 weeks):
2. Pt will get ROM WNL of R shoulder in order to be able to play tennis again for 30 min
each day.

PLAN OF CARE: Pt will be seen for physical therapy treatment 3x/wk for 8 wks.
Treatment will include STM of R GH joint, therapeutic exercises for strengthening R
shoulder, arm, and hand muscles, and sleep and postural education. Pt will continue to
apply ice to R shoulder prn at home. PT’s progress will be reevaluated each week, and pt
will progress to next phase of recovery as indicated.

___________________ SPT
PTH 633 SOAP Note Template THERAPIST NAME: Cara Stewart
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HEP for Julie Harris

Pendulums: Bend over at the waist and let R arm hang

down. Using your body to initiate movement, swing the
arm gently forward and backward and in a circular
motion. Complete for 1 min at a time, 4x/day.

Ball Squeezes: Hold a tennis ball in R hand and

squeeze 30 times, holding for 5 second with each
squeeze. Repeat 3x/day. *make sure R arm is resting
on pillow during exercise.

Scapular pinches: Pinch both shoulder blades backward

while R arm is in sling or resting on pillow. Complete 3
sets of 10 reps 2x/day.

PROM exercises: Carefully follow these instructions!

The pictures are slightly more advanced than the phase
you are currently in. Have mom assist with moving arm
for you. Be seated with R arm supported under pillow.
Have mom take you through motions of flexion, internal
rotation, and external rotation as done while in the
clinic. Do 10 reps in each position 2x/day. *Remember
with flexion to not bring arm past shoulder height, and
with internal and external rotation to only go to end range
that was completed in clinic.

*Also ride recumbent bike 30 min/day, 3x/wk and walk

around while watching tennis practice.
*Record activities on log and bring to each Pt appointment
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Exercise Activity Log for Julie Harris

Date Exercises How many Comments?
Completed times/day? (pain/issues)