Clinical Evaluation of Client B, #1.1

Client B
6'1, male, 69
Diagnosis: arthritis in wrists, ankles, and knees. Mild psoriasis. Medications: Tozarozene, NSAIDs (was not specific)

Subjective:
- retired attorney
- complains of lower back pain and stiffness in lower back (L5-S3 region) due to bulging disks
- discomfort in arthritic areas, but today only wrists feel inflamed
- requested special attention to traps, lower back, and knees

Observation:
- Elevated R trapezius
- swollen L and R ankles, more severe on R ankle
- swollen wrists
- signs of carpometacarpal thumb arthritis
- signs of hammertoe
- psoriasis most prominent on appendages (lower arms, hands, lower legs, feet)

Assessment:
- combination relaxation/therapeutic techniques
- relaxation: started in prone position to work out knots in the upper back/lower back. careful attention to wrists and fingers - light hand effleurage on fingers and moderate pressure on the palms. applied herbal adjustment/peppermint oil to wrists and thumb carpometacarpals. effleurage on the SCMs.
- therapy: moved Client B into supine position and rotated arms while compressing pectoralis insertion area. between moderate/firm pressure to the gastrocnemii + iliotibial tracts. special focus to the R ankle area to reduce swelling. ended with passive leg pulls, followed by passive hip rotation.

Plan:
- homework: consider lymph drainage work + continue recieving massages, especially passive stretch work for arthritic joints. continue taking medication/applying peppermint oils to wrists/ankles.
- drink water after each massage


Public Notes:
Client B is the oldest client I've had so far, and a great learning experience. His hand arthritis was pretty severe but that day it wasn't feeling too bad, so I was able to get a good look at (and even did some light work on) the irritation in his thumb and finger joints. Very interesting. I also saw some immediate results when I did the ankle work; the swelling went down considerably, foot temperature went up (a basic sign of increased circulation), and I noticed an increase in mobility during the stretching exercises. And most importantly, he left happy with the results.

If I could do it over again, I wish I had done a little bit of lymph drainage on his lower body. I think it would have helped with his psoriasis. Next time I'd also like to work on his abdominals, which I always hesitate to do when I've never worked with someone before. Working his psoas muscles should help with his hip/lower back pain.