MJis a 45-year old male, who have lived in the urban areas throughouthis life. He has been working as a mason since the age of 17 years.He is a husband and a father of two children. His own parents died ina road accident when he was at the age of 12 years. He dropped out ofhigh school and started engaging in casual labor to earn a living forhimself and his brother. His role as a mason has been to transportmaterials (including the building blocks and cement) to differentsections of buildings under construction. His interests includingswimming and watching movies. His wife, two children, and his youngerbrother are the major sources of his social support. He has neversuffered any should-related injuries, until the last four days whenhe fall from the second floor of a building that was beingconstructed in the central business district.
Thepatient feels severe pain that radiated through his arm. He expressesa limited range of motion, which was common during the abduction ofhis shoulder. The entire hand becomes too weak to lift or graspobjects. The affected should swells.
MJpresented four major symptoms. First, he felt during rest and atnight, especially when lying on the injured region. Secondly, MJ feltpain when lowering or lifting his arm. Third, he expressed someweaknesses when he attempted lifting or rotating his arm. Lastly, MJexperienced crackling sensation whenever he attempted to move hisshoulder in certain positions.
Rotatorcuff tear is a treatable condition that results from a degenerativetear or acute tear that is associated with lifting too heavy objects(Armstrong, 2011). An early diagnosis and treatment results in aquick recovery and help patients return to their normal routine.Effective recovery is achieved when the client stops lifting heavyobjects until tear gets over. The objective of treatment is to reducepain in the shoulder region and restore the lost functions.
Medicationis administered in two ways. First, the patient is provided withanti0-inflammatory drugs (such as ibuprofen) in order to control painand inflammation (American Academy Orthopedic Surgeon, 2013).Secondly, an injection with steroids (such as cortisone andanesthetics) is recommended when rest, physical therapy, and painrelief medication fails to end the pain.
Priorlevels of function
MJwas very active prior to the tear. He was able to lift standard-sizebuilding blocks and 50 kg cements of the bag. He could move his handsand should freely.
Thetreatment plan begins June 20, 2016.
MJwill be referred to a higher level of health care facility in casethe medication and other non-surgical therapies (such as rest andmodification of activity) fail to contain the pain and controlinflammation.
Duringthe treatment process, MJ should be restricted from engaging inactivities that require lifting of heavy objects or frequent movementof hands as well as the affected shoulder region.
MJis undergoing treatment in a word, where his progress is monitored byan assigned nurse. He is treated and monitored by an occupationaltherapist, a nurse, and a physician.
Dischargetime and location
MJwill be discharged after three days, on condition that the currenttreatment will be proven to be effective in reducing pain andswelling.
Lack of client’s response to medication
Change career to one that does not require lifting of heavy objects
Recommend a medical check-up at least once a year for the next five years
Engage in light physical exercise to strengthen muscles in the shoulder region
Non-surgicaltherapy: Under this treatment method, MJ will be required to stopengaging in hard tasks and take a rest. This treatment is recommendedbecause allowing the patient to continue working with the rotatorcuff tear makes the injury worse (Meijden, Westgard, Gaskill,Westgard, Kokmeyer & Millett, 2012).
Steroidinjection: Since severe pain is the major symptom expressed by thepatient, administering asteroid injection will contain the pain andallow the client to start the healing process (Haspal & Singh,2011).
Physicaltherapy: Physical therapy is an appropriate treatment that canrestore the strength and the movement of the shoulder to its initialfunctionality (Kuhn, Dunn, Baumgarten & Sanders, 2013).
AmericanAcademy Orthopedic Surgeon (2013). Rotatorcuff tears.Evanston: AAOS.
Armstrong,D. (2011). Rotator cuff tears. AmericanAcademy of Orthopedic Surgeons.Retrieved June 20, 2016, fromhttp://orthoinfo.aaos.org/topic.cfm?topic=a00064
Haspal,K. & Singh, G. (2011). Rotator cuff lesions: A case report.Journalof Exercise Science and Physiotherapy,7 (1), 56-63.
Kuhn,E., Dunn, R., Baumgarten, M. & Sanders, R. (2013). Effectivenessof physical therapy in treating a traumatic full-thickness rotatorcuff tears: A multicenter prospective cohort study. Journalof Shoulder and Elbow Surgery,1, 1-9.
Meijden,O., Westgard, P., Gaskill, T., Westgard, P., Kokmeyer, D. &Millett, J. (2012). Rehabilitation after arthroscopic rotator cuffrepair: Current concepts review and evidence-based guidance.InternationalJournal of Sports Physical Therapy,7 (2), 197-218.