PROGRESS NOTES

Name: Juan Antonio Echevarria Date: 3/28/23

Age/Sex: 62/M Date of Referral: December 2022
Status: Married Referring Dr.:
Handedness: Left Referring Unit:
Dx: (R) Adhesive Capsulitis, t/c (L) Shoulder Impingement
Precaution:

Dear Dr. __________

This is Juan Antonio Echevarria who was diagnosed to have (R) Adhesive Capsulitis. Pt was
seen and treated thru out-patient clinic for 15 sessions from November 3, 2022 to March 28, 2023 for 2x
a week. The following data are provided to serve as a reference for new interventions that may be given
or required by the patient.

Present Problem List:

1. Dull aching pain on (R) posterolateral side of the shoulder (PS 1-2/10)
2. LOM on (R) shoulder towards ER & IR as manifested by unable to reach the scapula
3. Postural Deviation:
a. Forward head
b. Increased thoracic kyphosis
Changes Noted:
1. Pt.’s pain decreased from (PS 5/10) to (PS 1-2/10)
2. Pt. exhibited ↑ AROM of abduction and IR from 175° to 180° and 65° to 70°

LTG: 3 wks of PT sessions

1. Pt. will be able to perform HEP specifically corner stretch exercise s pain & difficulty on (R)
shoulder p 3 wks of PT session

STG: To be achieved after ____months of PT Therapy

1. Pt. will be able to report ↓ pain on (R) post. shoulder from (PS 5/10) to (PS 3/10) p 2 wks of PT
sessions to aid in performance of ADLs such as wearing a backpack
2. Pt. will be able to demonstrate an ↑ ROM on (R) shoulder abd, IR & ER by 5° increment p 2 wks
of PT sessions to be able to perform ADLs c ease
3. Pt will be able to demonstrate an improvement in posture as manifested by practicing proper body
mechanics p 3 wks of PT session to avoid progression of postural deviation

OBJECTIVE:

OI:
• A/C/C
• Oriented x 4
• Mesomorph
• (+) Postural deviation (see postural ax)
 • (-) swelling
• (-) wound on (R) shoulder
• (-) mm atrophy on (R) UE
• (-) deformity on (B) UE

Palpation:
• Normothermic on all exposed body parts
• (+) taut bands on (R) upper traps
• (-) mm spasm on (B) shoulder
• (-) nodules on (B) shoulder

Range of Motion:
Previous: November 3, 2022
Present: March 28, 2023
Motion AROM AROM PROM PROM End-feel
(Previous) (Present) (Previous) (Present)
(R) Shoulder 175° 180° 180° 180° Firm
abduction
(R) Shoulder IR 65° 70° 70° 80° Firm
(R) Shoulder ER 80° 80° 90° 85° Firm
Findings: Pt initially presents c LOM of (R) shoulder abduction, IR, and ER but has now improved c 5°
increments.
Significance: Pt.’s improvements indicates that the treatment has shown good progression and if
continued may be able to fully ↑ ROM of shoulder motion.

Manual Muscle Testing:

Previous: November 3, 2022
Present: March 28, 2023
All major muscles of (B) UE & LE are graded 5/5
Significance: Pt. has normal muscle strength on (B) of his shoulder s any pain and discomfort during the
assessment.

Postural Assessment:
Previous Present
Anterior (R) shoulder slightly higher than (R) shoulder is slightly higher
(L); Elbow crease unleveled than the (L) shoulder
Lateral Slight forward head Forward headed; Rounded
Rounded shoulders (R>L) shoulder on the (R) Slight ↑
thoracic kyphosis
Posterior (R) shoulder slightly higher than (R) shoulder is slightly higher
(L); Rounded shoulder (R>L) than the (L) shoulder
Findings: Pt. shows no improvements c his posture
Significance: Pt.’s postural exercises should be done regularly to improve his posture.
P:
Current PT Mx:
1. MFR on (B) upper traps x 5’
2. Rhomboid stretch x 30 SH x 3 reps
3. Pectorals stretch x 30 SH x 3 reps
4. GPS of (B) upper traps x 30 SH x 3 reps
5. GPS of (R) shoulder flexion & abduction 30 SH x 3 reps
6. Pendulum Exercise on (R) shoulder towards AP using 3.3 lbs DB x 10 reps x 2 sets
7. MAI of (B) shoulder towards Et & IR c elbows flexed at 90 deg & adducted using all 4 theratubes
x 6SH x 10 reps x 2 sets
8. D2 flexion of (R) shoulders using all 4 theratubes x 6SH x 10 reps x 2 sets
9. Shoulder rolls of (B) shoulder x 10 reps x 2 sets
10. TENS while doing wand exercise on (R) posterolateral shoulder in AP x 180 hz x 50 us x 7SH x
10 reps x 2 sets
11. TENS while doing finger walk the wall on (R) posterolateral shoulder x 180 hz x 50 us x 7SH x
10 reps x 2 sets
12. PREs (B) shoulder towards flexion & abd using 3.3 DB in x 10 reps x 2 sets
13. Postural Exercises:
a. Chin tucks while leaning against the wall x 6SH x 10 reps x 2 sets
b. Scapular retraction using 4 theratubes arched on the bar outside in sitting x 6SH x 10 reps
x 3 sets
14. Towel stretch towards ER and IR (R) shoulder x 15SH x 4 reps x 2 sets

Suggested PT MX:
1. Grade III Joint Mobilization c posterior glide x 2-3 oscillations/sec x 2’
2. Scapular mobilization in AP x 20 reps

Prepared by: Received by:

Jastine Abigaile D. Labastida Alfonso Miguel L. Lagazon, PTRP

PLM PT Intern 2022-2023 PT-staff-in-charge