Scleroderma Case Study

Author/s

Catelin Infante, Jessica Frederick, Kristin Casagrand, Jarrod Smith from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

100 word limit, non-structured description

Patient Characteristics

• Demographic Information: (occupation/vocation, gender, age, etc.)                                                                                                       

Native American 

Female

Born and raised in Oklahoma 

Works in a factory 

Thirty-five years old 

Family history of rheumatoid arthritis on mother's side 

• Medical diagnosis if applicable

Scleroderma 

• Co-morbidities

Hypertension, Type II Diabetes 

• Previous care or treatment

Previous physical therapy for low back pain 

Examination

  Subjective 

Mrs. Smith comes into the clinic complaining of joint pain and muscle weakness, especially in her hands, hips and shoulders¹. She explains that she has been having trouble making it through a full day of work because her body feels limited and she just cannot reach as well for boxes at her job because “her arms won’t go up that far.” She also has noticed that she gets out of breath and sometimes has chest pain when she lifts a lot too quickly². Mrs. Smith indicates that her fingers often feel very swollen and stiff and sometimes feel “stuck” in a bent position1. She reports that for several months she has been getting a really cold, numb feeling in her fingers throughout the day, especially when she is sitting in the air conditioning at her office³. Overall, she has just not felt well for the past few months either. When she eats, she has trouble fully opening her mouth to put food in². Then, when she lies down at night after dinner, she gets a feeling of heartburn and sometimes feels like she has to vomit¹. However, she says she has been eating poorly lately, so it’s probably her fault she hasn’t felt well. Additionally, Mrs. Smith reports losing 20 pounds in the past month without any lifestyle changes. Her goals for therapy are to decrease her joint pain and to get her muscles stronger so she doesn’t struggle at work any longer. Her focus is on getting her hands and arms “back to normal” because they are what she uses most in her job.

 

Self Report Outcome Measures<o:p></o:p>

·      Health Assessment Questionnaire Disability Index (HAQ-DI)⁴: 1.1

·      Disabilities of Arm, Shoulder, and Hand Questionnaire (DASH)⁵: 34

·      Verbal Pain Intensity Scale: “Severe pain”

 

 

Physical Performance Measures<o:p></o:p>

·      Grip strength (R)⁶: 20.7 kg

·      Grip strength (L)⁶: 19.18 kg

·      Pinch strength (R)⁶: 4.27 kg

·      Pinch strength (L)⁶: 3.98 kg

·      Oral aperture⁷: 28 mm

 

Objective <o:p></o:p>

·      MMT: WNL except for the following

o   4/5- finger and thumb abduction, adduction, flex, ext

o   4/5- wrist flex and ext

o   3+/5- shoulder flex and abduction

o   3+/5- hip flex and abduction

·      ROM: WNL except for the following

o   decreased flexion and extension in all finger MCP and IP joints

o   decreased wrist flexion and extension

o   decreased hip extension and abduction

·      Reflexes: WNL

·      Sensation:

o   Decreased facial sensation

 

ICF Findings

^·               Impairments^1,2,8

o   Patient is has stiffening around fingers and what appears to be finger flexion contractures developing

o   Patient has noticeable hard deposits palpated around UE joints

o   Patient has slurred speech due to difficulty fully opening mouth. The skin around the face is thickened and has begun to cause puckering.

o   Patient has dyspnea and chest pain upon exertion.

·      Activity limitations^1,2,8

o   Patient is unable to complete activities in supine secondary to reflux symptoms

o   Patient is unable to complete overhead activities due to decreased shoulder ROM.

o   Patient is unable to complete more than 30 minutes of repetitive movements due to fatigue, muscle weakness, and joint pain.

·      Environmental factors⁸

o   Patient is employed as a packer at a plastics company.

o   Patient is a smoker of 20 years.

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• Phases of Interventions (e.g. protective phase, mobility phase, etc.)
• Dosage and Parameters
• Rationale for Progression
• Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

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