Clinical Evaluation of Client A, #1.1

Client A
5'3, female, 20
Diagnosis: scoliosis of the spine diagnosed in her early teens. No medication.


Subjective:
- complains of cracking joints and hip pain
- enjoys dance, but cannot continue (doctor's orders)
- first massage
- wants increased mobility & stretching tips

Observation:
- elevated left shoulder
- elevated right hip
- medially rotated arms
- medially pronated feet (more severe on right foot)
- knots in L5/S1 area

Assessment:
- mainly relaxation massage with some therapeutic techniques (promotes comfort + not overly intrusive for a beginner massage)
- therapy: rotated scapula (R, L was too tight), compression work on quads w/random rotation technique, trigger points on traps
- relaxation: arms, fingers, feet, gastocs, deep petrissage for lower back

Plan:
- homework: get up after using the computer for more than 1 hour, get a cervical pillow/replace old bed pillow (pillows should be discarded after 1 yr of use), don't wear the same shoes all the time & retire worn shoes after 6 months or get them re-soled
- drink plenty of water after a massage



Public Notes:

New clients are usually a bit nervous, so I've found it's better to just proceed with a run-of-the-mill Swedish massage before bombarding them with all their problems and how to fix them. I also rarely turn over clients on their first time, which was the case here, even though she definitely could have used the pec/abdominal work. Turning over clients interrupts flow and can be disorienting, and it's also a matter of exposure and comfort level.

That said, I love first timers. Most of them don't know what to expect and end up falling asleep, giving me time to slow down and play around with techniques. It's also a great compliment; it tells me the client is comfortable and completely relaxed.