Case Study

Age, Gender & Diagnosis

46 year-old right hand dominant female with a left hand contractural atrophy (flexible
boutonniere)
History
Patient has a history of COPD, Asthma, and Bronchitis
Patient is allergic to Aspirin.
Patient is on Naproxen and Tylenol.
Patient was not working at time of onset, which was in 1999.
Patient used to paint and do woodworking.
Upon admission patient showed: LUE Strength RUE Strength
Shoulder flexion 4/5 WNL
Shoulder Abduction 4/5 WNL
Shoulder Int. Rot. 4+/5 WNL
Shoulder Ext. Rot. 4+/5 WNL
Elbow flexion 4+/5 WNL
Elbow extension 4+/5 WNL
Forearm supination 4+/5 WNL
Forearm pronation 4+/5 WNL
Wrist flexion 4+/5 WNL
Wrist extension 4-/5 WNL
Grip 22# 71#
Lateral pinch 10# 14#
Palmer pinch 7# 13#
LUE AROM
Shoulder flexion 120
Shoulder abduction 95
Shoulder Int. Rot. 75
Shoulder Ext. Rot. 60
Elbow flexion WNL
Elbow extension WNL
Forearm supination WNL
Forearm pronation WNL
Wrist extension 50
Wrist flexion 60
Digits: MP PIP DIP
Index -25/75 -40/100 +20/45
Long -40/90 -50/105 +35/30
Ring -35/90 -35/100 +15/45
Small -35/90 -50/100 +10/55
CMC MP IP
Thumb 70 -5/45 +55/30
All AROM of RUE is WNL.
Problem Areas
Patient has problems with Fine Motor Control, Tremors, Thoracic kyphosis with a Right
lateral shift, difficulty with buttoning and hair care. Patient denies sensation loss.
Goals
LTG: Patient will increase functional use of her LUE, with or without use of assistive
devices by discharge.
STG: Patient will demonstrate Independence in a HEP throughout treatment.
STG: Decrease subjective pain reports by 2-3 levels in 2 weeks.
STG: Patient will increase strength and mobility of left shoulder to allow patient to
perform hair care in 2 weeks.
LTG: Patient will increase FMC to allow buttoning of clothing by discharge.
STG: Patient will increase FMC to allow patient to button clothing with large buttons
within 2 weeks.
STG: Patient will increase FMC to allow patient to button clothing with small buttons
within 4 weeks.
STG: Patient will increase left grip and pinch strength by 10% to facilitate ability to grasp
and hold items in left hand in 2 weeks.
Treatment Plan with Frame of Reference
Patient will be seen in clinic 3 x’s a weeks for 8 weeks for finger ROM, Strength and
flexibility, wrist ROM and strength. Uses frames of references like the Biomechanical
and MOHO.
Specific Activities
Assessments: Dynamometer, pinch gauge, and grooved pegboard.
Fluidotherapy, bolt board, theraputty, theraputty with beads, theraputty with cylinder,
pegboards, hand gripper and stringing beads.
Expected Outcomes
I feel that if the patient continues to try and keeps up with her HEP then she will make a
complete recovery and get back to the things that she enjoyed before.