Progress Note

History of Present Condition

Sarah Jenkins, a 54-year-old female (MRN: 842-109-44), presents on 24/05/2026 at 09:30 for follow-up occupational therapy 6 weeks post-open reduction and internal fixation (ORIF) of a right distal radius fracture. The injury occurred following a fall onto an outstretched hand on icy pavement. She reports a dull ache in the right volar wrist rated 3/10 at rest, increasing to 6/10 with end-range supination and heavy gripping, though overall swelling has decreased since last week. Sarah states, "My wrist still feels very stiff in the mornings, and I am struggling to turn heavy doorknobs or lift my kettle with my right hand." Prior to the injury, she was independent in all activities of daily living (ADLs) and worked full-time as an administrative assistant, where she currently remains on light duty due to typing and lifting restrictions. Her primary goal is to regain sufficient wrist mobility and grip strength to return to full work duties and resume gardening; she notes positive incremental improvements from her home exercise program and paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN prior to therapy sessions.

Objective

• Static Postural Observations

  • Mild protective flexion posture held at the right elbow and wrist during ambulation.
  • Well-healed 5 cm longitudinal surgical scar over the right volar forearm without erythema.

• Range of Motion (Right Wrist and Forearm AROM)

  • Wrist flexion: 0–45 degrees
  • Wrist extension: 0–40 degrees
  • Radial deviation: 0–10 degrees
  • Ulnar deviation: 0–20 degrees
  • Forearm supination: 0–60 degrees
  • Forearm pronation: 0–75 degrees

• Strength Testing (Right Upper Extremity MMT & Dynamometry)

  • Wrist flexion: 4-/5
  • Wrist extension: 3+/5
  • Forearm supination: 3+/5
  • Gross grip strength (Jamar dynamometer, position 2): 12 kg (Left: 28 kg)
  • Lateral pinch strength: 4.5 kg (Left: 7.5 kg)

• Therapist Observations and Special Tests

  • Mild adherences noted along the central aspect of the volar scar with decreased tissue glide.
  • Phalen's test: Negative for median nerve paresthesia.
  • Composite finger flexion: Tips of digits 2–5 touch the distal palmar crease smoothly.

• Specific Measurements and Assessment Findings

  • Figure-of-eight wrist circumference measurement: 16.5 cm on the right, compared to 15.8 cm on the left.
  • QuickDASH disability/symptom score: 38.6%.

• Vital Signs

  • BP: 124/78 mmHg
  • HR: 72 bpm
  • RR: 14 breaths/min
  • Temp: 36.8 °C

• Physical and Mental Status Examination

  • Neurological: Sensation intact to light touch across radial, ulnar, and median nerve distributions; radial pulse 2+.
  • Mental status: Alert, oriented x4, cooperative, with good comprehension of rehabilitation protocols.

• Investigations

  • Right wrist radiographs (20/05/2026): Satisfactory alignment of volar locking plate and screws with bridging callus across the distal radius fracture site.

Assessment

Sarah demonstrates steady clinical progress following right distal radius ORIF, presenting today with residual joint capsule stiffness, mild localized edema, and decreased grip strength limiting her bilateral upper extremity IADLs and work tasks. Since her evaluation two weeks ago, Sarah has gained 10 degrees of active wrist extension and 15 degrees of supination, alongside a 3 kg improvement in right gross grip strength. Progress is slightly tempered by morning stiffness and scar adherence, requiring the addition of targeted scar mobilization and progressive strengthening to her current plan of care. No external referrals are indicated at this time as fracture healing is routine per recent orthopedic radiographs. Sarah tolerated today's manual therapy, thermal modalities, and therapeutic exercises well, demonstrating improved tissue extensibility and reduced pain post-mobilization. She was educated on ergonomic workstation modifications and proper scar massage techniques to perform independently. Sarah continues to use a prefabricated cock-up wrist splint exclusively for high-risk community activities and heavy lifting protection, having successfully weaned from daytime use at home. "The patient is expected to continue benefiting from skilled physical therapy to address the impairments and limitations described above and support a return to chosen activities."

Charges & Exercises Performed

• Therapeutic Exercise (97110 - 15 mins): Active-assisted and active ROM exercises for wrist flexion/extension and forearm supination/pronation (3x10 reps); tendon gliding exercises (2x10 reps); gentle isometric wrist strengthening and yellow TheraBand® concentric wrist extension (2x12 reps).
• Manual Therapy (97140 - 15 mins): Grade II and III radiocarpal volar/dorsal glides and distal radioulnar joint (DRUJ) mobilizations to increase extension and supination; direct soft tissue mobilization and cross-friction massage to the volar surgical scar.
• Therapeutic Activities (97530 - 15 mins): Functional grasp and release training using medium-resistance therapy putty; simulated work tasks including bilateral typing posture drills and lifting a 1 kg weighted box with neutral wrist alignment.
• Plan Frequency and Duration: Continue outpatient therapy 2x/week for 4 weeks.

Patient Education and Counselling

• Instructed Sarah to perform retrograde edema massage and scar mobilization using unscented lotion for 5 minutes, 3 times daily.
• Advised on ergonomic keyboard and mouse placement at work to maintain a neutral wrist posture and avoid prolonged end-range extension.
• Counselled on pacing strategies for home and gardening tasks, maintaining a maximum right-hand lifting limit of 2.5 kg until cleared by the orthopedic surgeon.