SUBJECTIVE

I. General Information

Patient’s Name: P.T.R

Age: 20 years old
Sex: Female
Address: General Luna, Baguio city
Civil status: Married
Handedness: Left
Occupation: Office worker
Religion: Roman Catholic
Referring Dr.: Dr. John Edward A. Sigan MD, FPOA
Rehab Dr.: Dr. Helena Conce D. Branc MD, DPT
Date of Consultation: September 19, 2019
Date of Referral: September 19, 2019
Date of IE: September 20, 2019
Date start of Rehab: September 21, 2019
Diagnosis: Dactilitis secondary to maternal Grave’s Diseases

II. C/C

“C/C: “Masakit ang mga kamay ko at hindi ko naigagalaw ng maayos” P/S 8/10

PT Translation: “My hands are painful and I cannot move them properly” P/S 8/10

Patient’s Goal: “Mawala ang sakit at maigalaw ko ang mga kamay ko ng maayos. ”

PT Translation: “To be able move my hands pain free.”

III. HPI

Present condition started September 17, 2019 when patient is in the office. Px stated that she experience

tremor associated with pain in her both hands with P/S of 8/10. Patient took 400mg of Medicol 20 minutes after

she had tremors to ease the pain in her hands and felt a decrease of pain from P/S 8/10 to P/S 6/10. Px was

able to continue her work for 4 hours and took a cab going home. Px took 400 mg of Medicol again when she

got home and was able to sleep. Patient continued her work for the next day by continuous taking of 400mg of

Medicol every 6 hours and notices that her tremors in her fingers are getting worst. This prompted her to consult

with Dr. Edward an orthopedic at Sacred Heart Hospital on September 19, 2019. She was asked to undergo

blood test to check for her hormone levels and ancillary procedures (check ancillary procedures). Patient was

diagnosed with dactylitis secondary to Grave’s disease and was referred to UBPTC for further evaluation and

treatment of her hand tremors that is associated with pain.

IV. Ancillary Procedure

BLOOD TEST

Date: September 19,

2019

Hormone Normal range Result Findings

 Free T4 9-20 pmol/L 35 pmol/L Elevated

Free T3 3-6 pmol/L 12 pmol/L Elevated

ANCILLARY REQUESTING
DATE RESULT
PROCEDURE DOCTOR

Dr. John Edward A.

September 19, 2019 X-Ray Unremarkable
Sigan

Dr. John Edward A.

September 19, 2019 MRI Unremarkable
Sigan

V. Medications

MEDICINE DOSAGE INDICATION ADVERSE REACTIONS

GI disorders, struma, exophthalmos,

50 mg/ every leukopenia, thrombocytopenia,
Propylthiouracil Antithyroid drugs
6 hrs agranulocytosis and thyrotoxic crisis,
after having discontinued prep.

Nausea, vomiting, gastric discomfort,

headache, arthralgia, skin rashes,
Methimazole 15 mg/ daily Antithyroid drugs
pruritus, hair loss, Bone marrow,
depression, mild leukopenia.

Gastric mucosal damage resulting in

ulceration &/or mucosal bleeding,
dyspepsia, heartburn, nausea,
Medicol 400 mg NSAIDS
vomiting, anorexia, diarrhea,
constipation, stomatitis, flatulence,
bloating, epigastric, abdominal pain.

VI. Past Medical and Surgical History

( + ) Hospitalizations (dx c Graves dse, November 2001)

(-) HTN
( -) DM
( - ) Hospitalizations
( - ) Surgeries
( - ) Allergies (food and drugs)
( - ) Arthritis
( - ) Cancer

VII. Family Medical History

CONDITION MOTHER FATHER

HTN (+) (-)

DIABETES (-) (+)

ARTHRITIS (-) (-)

CAD (-) (-)

 CANCER (-) (-)

VII. PERSONAL, SOCIAL AND LIVING ENVIRONMENT

Patient is a 20 y/o office worker, she encodes and do paper works for 8 hours a day, 6 days a week. Patient
drives a car for 20 minutes going to work and uses the elevator to reach her workplace which is located at the
6th floor of the building.

Patient is single.
Patient is non-smoker.
Patient is an alcoholic drinker.

Home situation:
Patient lives with her family in a villa.
Main road to house: 15 steps
Main door to bed: 20 steps
Bed to bathroom: 9 steps
Bed to kitchen: 20 steps
Bed to living room: 25 steps

OBJECTIVE

I. Vital Signs

VITAL SIGNS BEFORE DURING AFTER

TREATMENT TREATMENT TREATMENT

BLOOD PRESSURE 110/70 mmHg 130/80 mmHg 110/70 mmHg

HEART RATE 99 bpm 115 bpm 100 bpm

RESPIRATORY 21 cpm 27 cpm 22 cpm

RATE

TEMPERATURE 36.9oC 37oC 37oC

O2 SATURATION 95 mmHG 95 mmHG 95 mmHG

II. Ocular Inspection

 Ambulatory without Assistive Device
 Ectomorph
 A/C/C x 4
 Exophthalmos
 (+) Swelling on all bilateral phalanges
 (+) Tremor of hands
 (+) Enlarged thyroid
 (+) Rubor on all bilateral phalanges
 (-) Postural deviation (See Postural analysis)
 (-) Gait Deviation (See Gait Analysis)
 (-) Contractures
 (-) Atrophy
 (-) Scars
 (-) Hematoma
III. Palpation

 (+) Hyperthermia
 (+) Warm thryoid
 (-) Edema
 (-) Tenderness
 (-) Joint crepitation
 (-) Muscle spasm
 (-) Taut band
 (-) Subluxation
 (-) Nodule

IV. Range of Motion

Wrist

Right

AROM PROM Normal Difference End Feel

ROM

AROM PROM

Flexion 0-66 0-68 0-70 4 2 Empty

Extension 0-74 0-77 0-80 6 3 Empty

Ulnar 0-25 0-27 0-30 5 3 Empty

Deviation

Radial 0-17 0-20 0-20 3 0 Empty

Deviation

Right
1st finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-55 0-60 0-90 35 30 Empty

Extension 0 0-0 0-0 0 0 Empty

2nd finger

Distal
interphalangeal AROM PROM Difference End Feel
 Normal
ROM

AROM PROM

Flexion 0-50 0-55 0-90 40 35 Empty

Extension 0 0-0 0-0 0 0 Empty

3rd finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-50 0-55 0-90 40 35 Empty

Extension 0 0-0 0-0 0 0 Empty

4th finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-55 0-60 0-90 35 30 Empty

Extension 0 0-0 0-0 0 0 Empty

Thumb
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-40 0-45 0-80 40 35 Empty

Extension 0 0-5 0-20 20 15 Empty

Wrist

Left

AROM PROM Normal Difference End Feel

ROM

AROM PROM

Flexion 0-60 0-65 0-70 10 5 Empty

 Extension 0-70 0-75 0-80 10 5 Empty

Ulnar 0-23 0-25 0-30 7 5 Empty

Deviation

Radial 0-14 0-18 0-20 6 2 Empty

Deviation

Left fingers
1st finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-80 0-85 0-90 10 5 Empty

Extension 0 0-0 0-0 0 0 Empty

2nd finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-80 0-85 0-90 10 5 Empty

Extension 0 0-0 0-0 0 0 Empty

3rd finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-80 0-85 0-90 10 5 Empty

Extension 0 0-0 0-0 0 0 Empty

4th finger

Distal
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-80 0-85 0-90 10 5 Empty

 Extension 0 0-0 0-0 0 0 Empty

Thumb
interphalangeal Normal
AROM PROM Difference End Feel
ROM

AROM PROM

Flexion 0-70 0-75 0-80 10 5 Empty

Extension 0-15 0-20 0-20 5 0 Empty

Findings: Limitation in all of planes of motion on both right and left wrist, finger DIP and thumb IP
Significance: Secondary to decreased muscle strength

V. Manual Muscle Testing

Wrist RIGHT LEFT

Flexion 2+/5 2+/5

Extension 2+/5 2+/5

Radial Deviation 2+/5 2+/5

Ulnar Deviation 2+/5 2+/5

Finger muscle group RIGHT LEFT

Flexor proximal phalangeal 2 + /5 2 + /5

Flexor distal phalangeal 2 + /5 2 + /5

MP Flexion 2 + /5 2 + /5

MP Extension 2 + /5 2 + /5

Abduction 2 + /5 2 + /5

Adduction 2 + /5 2 + /5

Thumb muscle group RIGHT LEFT

MP flexion 2 + /5 2 + /5

MP extension 2 + /5 2 + /5

IP Flexion 2 + /5 2 + /5

IP Extension 2 + /5 2 + /5

Abduction 2 + /5 2 + /5

Adduction 2 + /5 2 + /5

Opposition 2 + /5 2 + /5

Findings: Decreased muscle strength on wrist, finger and thumb.

Significance: Secondary to muscle weakness.

VI. Postural Analysis

Lateral View:

Head Slightly extended

Mandible Resting
Scapula Protracted
Thoracic Normal kyphosis
Lumbar Normal lordosis
Pelvis Slightly tilted posteriorly
Knees Normal
Feet Normal

Anterior/Posterior View

Head Aligned
Mandible Resting
Scapula Levelled
Pelvis Levelled
Hips Levelled
Knee Creases Level
Ankles Eversion
Feet Pronation

Findings: All WNL except head is slightly extended.

Significance: Secondary to enlarged thyroid.

VII. DTR:

(R) (L)

+++ +++
LEGEND:

+ HYPOREFLEXIA

++ ++ ++ NORMOREFLEXIA

+++HYPERREFLEXIA

++ ++ ++++ CLONUS

+++ +++

Finding: Hyperreflexia
Significance: Possible affectation of the UMNL.

VII. Gait Analysis

Right Left

Stance Phase:
 Heel strike Normal Normal

Foot flat Normal Normal

Midstance Normal Normal

Heel off Normal Normal

Toe off Normal Normal

Swing Phase:

Acceleration Normal Normal

Mid swing Normal Normal

Deceleration Normal Normal

Finding: Normal gait analysis

Significance: Normal gait

IX. Activities of Daily Living

SELF CARE

A. Eating 5

B. Grooming 5

C. Bathing 5

D. Dressing- Upper 4

E. Dressing- Lower 4

F. Toileting 4

SPHINCTER CONTROL

G. Bladder 7

H. Bowel 7

TRANSFERS

I. Bed, Chair, Wheelchair 7

J. Toilet 5

K. Tub, Shower 5

LOCOMOTION

L. Walk 7

M. Stairs 7

COMMUNICATION

N. Comprehension 7
O. Expression 7

SOCIAL COGNITION

P. Social Interaction 7

Q. Problem Solving 7

R. Memory 7

GRADING:

7- Complete independence

6- Modified independence

5- Supervision

4- Min. Assistance

3- Mod. Assistance

2- Max. Assistance

1- Total Assistance

Findings: Patient has completed independence except for dressing both UE and LE and in toileting.
Significance: Secondary to pain associated with tremor.

ASSESTMENT

PT Impression:

A 45-year-old female office worker complains of difficulty in grabbing objects, (p/s 8/10) tremor and feels
fatigue most of the day. This thus making self-care ADL difficult. There is a decrease right finger and thumb ROM
and decrease strength secondary to pain. Patient’s left shoulder is higher than the right shoulder, secondary to
muscle tightness. Patients is hyper reflexive on elbow and patellar reflexes. Patients has Grave’s diseases.

Rehab Potential: Patient has a good rehab potential due to her cooperativeness and willingness to participate in
the physical therapy interventions. Patient’s friends and family are supportive giving good morale to the patient.

Problem List:

1. Decrease right fingers distal interphalangeal range of motion

2. Decrease thumb range of motion
3. Decrease muscle strength on right and left hand
4. Fatigue
5. Muscle tightness on shoulder

Short Term Goal: 3x/ for 3 weeks (6 sessions)

1. Decrease pain on Right and Left hands from 8/10 to 4/10.

2. Increase bilateral wrist and all finger ROM by increments of 5.
3. Increase thumb ROM in all planes by increments of 5.
4. Increase muscle strength on bilateral wrist and all finger motion from 3/5 to 4/5
Long Term Goal: 3x/ for 4 weeks (9 sessions)

1. Eliminate pain from 4/10 to 0/10

2. Achieve full ROM on bilateral wrist and all fingers
3. Achieve a full ROM of thumb in all planes.
4. Achieve a 5/5 MMT on wrist and finger motions
5. Patient does not feel fatigue throughout the day

PLAN

PT Management:

1. Cryotherapy on Right and Left wrist x 15 mins

2. AROM exercises x 15 reps x 3 sets
3. Grade 1 joint mobilization on bilateral hands
4. Resistance exercises of Right and Left fingers x10 sec hold x 5 reps x 3 sets
5. Increase strength of wrist finger flexors, extensors
Home Exercise Program:
1. Isometric exercises
2. Self-stretching exercises
3. Low impact exercises
Precaution

1. Px may have to consult with her doctor to consider other drugs that will not exacerbate the manifestation of
her dse esp. with hair loss and exopthalmus.

2. Monitor px BP during tx especially when px experiences pain

Carullo, Arvin C.
PT Intern 2019

Pagsibigan, Helder Daniel A.

PT Intern 2019

Binohlan, Bethzaida A.
PT Intern 2019

Dumecquias, Heidi Lynn N.

PT Intern 2019

Kiswa, Kae B.
PT Intern 2019