- Name: Mr.

Bun Heab
- ID: BSP220013 CLINICAL REASONING FORM B
- Phreash Kosomak Hospital

This is to be completed after the patient physical assessment and treatment.

1. Describe the patient (age, gender, occupation, brief history of main complaint,
relevant past history if any)

-Mr. Lam Kouy in the ages of 30years old.

He works in office and living in Phnom Penh.
He feel pain on the right of elbow 5/10 in right
Elbow flexion caused by traffic accident 22.09.22.
He was operation on the right 1/3 Distal Humerus
Close # with Plate Screws more than 2months.
After that, he worry about his elbow bending because
he feel hard to move his hand in his life. Then, doctor
requested him to get Physiotherapy service at
Preash Kosomak Hospital.

2. BODY CHART & INTERPRETATION

a. Complete the body chart and clearly label each symptom location (VAS,
associated symptoms, relationship)

- Tightness Pain 5/10 when flexion and extension.

- Pain going down 3/10 when relaxing 15minutes.

3. INTERPRETATION OF THE PHYSICAL EXAMINATION

3.1 Which specific physical examination findings are related with the
patient’s complaints/functional limitations?
Active (degree) Passive (degree)
- AROM: Right Elbow Exten -65 -55
Elbow Flex 90 100
Supination 40 50
Pronation Full Full
- Muscles M+ Right Elbow Flex: 2/5, Elbow Exten: 3/5
- Sensory: Good

3.2 What medical or radiological investigations have been carried out?

- X-Ray: 15.12.22
What are the main findings and are they relevant to the patient’s disorder?

- X-Ray: With strong callus on right Distal of Humerus

Will the radiological findings influence your treatment plan?

State your reason.
- X-Ray: Is much important when stretching joint.
- Especially, during Elbow Flex and Exten.
- To avoid bad things.
4. ANALYSIS OF THE DISORDER

4.1 What is the patient’s diagnosis?

- Right 1/3 Distal of Humerus Close #

4.2 What is the expected prognosis?

- That is Good

State your reasons.

- Because I have the objective assessment to evaluation the improving ROM

and muscles strengthening. The patient do exercises at home. It will take
3weeks to be better.

4.3 List the patient’s problem list (Max 3).

- Tightness and Pain 5/10 on right elbow and no numness referred to wrist
- Stiffness right elbow in flexion and extension.
- Hard to bending and extension right elbow.

4.4 List your STG and LTG for this patient (patient centered approach) and
the time frame to achieve them.

- STG: - Reduce pain 5/10 to 3/10 right elbow in (3weeks)

- Increase ROM right Elbow Exten -65degree to -50degree (3weeks)
- Increase ROM right Elbow Flex 90degree to 100degree (3weeks)
- Improve Muscles strengthening in elbow flex 2/5 to 3/5 (2weeks)
- Improve Muscles strengthening in elbow exten 3/5 to 4/5 (2weeks)
- LTG: - Ability to move his hand in office and more easily (6-12weeks)
5. MANAGEMENT AND EVALUATION

5.1 What is your treatment for Day 1?

- Soft tissue technique (5-10minutes)

- Gliding right elbow 60 movements in 3sets.
- Stretching Joint 1 to 3 minutes in 5-10 movements.
- Passive Mobilization 30 movements 10 moments relax 1minute.

5.2 What asterisk signs would you use to evaluate your treatment
outcome? (you may include outcome measures)

- Reduce pain (Pain Scale)

- Soft tissue release (Muscle length and compare with healthy side)
- Improved ROM (Goniometer)

5.3 List your plan for the next session assuming that the patient is
a) better

- Observation about treatment with the same technique and add more exercises.

b) same

- Re-evaluation the assessment and add more exercises.

c) worse

- Re-evaluation and change the technique with according to Physical

Examination on needed.