Patient Note (Alice)
Alice
(Patient ID 018)
| Name: Alice | Age: 39 | Admit date: N/A | MR #: 000-018 |
| Gender Identity: Female | Race: White |
Admitting diagnosis: Rotator Cuff Repair |
Insurance: BCBS |
| History of present illness: 39-year-old female reported gradual shoulder and hand weakening and altered sensation in R shoulder. She states that while attempting to lift a suitcase into an airplane overhead bin she heard a pop and experienced acute weakness and pain. A few days later she fell and caught herself using her R arm. After her fall she was unable to use her R upper extremity. MRI revealed a full thickness complete tear of the supraspinatus and partial tear of the infraspinatus tendon. Arthroscopic R rotator cuff repair and R carpal tunnel release surgery were performed. | |
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Past medical/surgical history: Rotator cuff repair on L side 3 years ago Carpal tunnel symptoms in L wrist |
| Social History: Lives at home with husband and 2 children. She enjoys gardening and crafting (primarily paper crafts) in her spare time. | |
| Employment/work/school: Currently employed part-time as a nurse working two 12-hour shifts weekly. | |
| Prior level of function: Prior to her current injury she was independent at work and at home. Her shoulder weakness required some activity modification including requiring a second assistant for transferring patients at work and avoiding overhead reaching at home. She also reported difficulty typing for long periods of time while charting. |
Weeks 0-6: Wear sling continuously (may be removed for exercises, showering, and dressing). Pain medication PRN. Complete given HEP 4x day, scar massage 4x day. PROM only. No joint mobilization.
Weeks 6-12: No lifting more than 5 lbs or overhead reaching. AAROM progressing to AROM. No strengthening exercises.Weeks 12+: Progress to strengthening exercises as tolerated.
Tylenol 650mg TID PRN
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.