Professional Documents
Culture Documents
PT Diagnosis (ICD-10): Lateral epicondylitis right elbow M77.11, carpal tunnel syndrome, right
upper limb G56.01, pain in right forearm M79.631
SUBJECTIVE:
History of current complaint:
Patient is a 33-year-old, male, right -handed plumber with a referral of R forearm pain.
His primary complaint is pain, rating a 3/10, in the R lateral forearm and pain, rating a
3/10, in the R wrist. This pain increases to an 8/10 when pt is “gripping tools and
participating in hobbies.” Pt’s hobbies include wood bowl turning, cooking, bowling,
gardening, and spending time with his kids (ages 1 and 3). Pt noticed onset of pain “about
1 and ½ weeks ago.” Pt came in with cheap, unsupportive wrist brace, stating: “the doctor
told me to get this, but it is not working.” The pt has also mentioned sleeping on his R
side in a curled R arm and R wrist position. Pt experiences tinging in R arm at night. Pt
also stated that at the end of the day the R elbow is “hot and swollen” and the hand feels
“sleepy.”
Current Functional status/activity/participation level:
Pt is currently able to sit and stand with no issues. Pt has a hard time flexing and
extending the wrist without pain (8/10). Pt is also having pain with cooking, working,
picking up kids, gardening, bowling, and wood turning. The R elbow and R wrist
experience 8/10 pain with these activities, severely slowing them down and restricting a
few (picking up kids, bowling, wood turning).
Prior level of function:
Pt could previously complete all normal hobbies and job activities without and deficits.
Medical/Surgical history; general health status (Review of Systems):
Pt. has no medical/surgery history and is in good health.
Current medications:
Therapist Name: ___Anja Bliss____
Lab (AM/PM): __________PM_____
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): __________B______
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Pt. is currently taking Ibuprofen to deal with pain. More details included in drug screen
sheet.
Allergies:
N/A
Employment status: Pt. is a self – employed plumber who does lots of bending over and
the hips and supination/pronation of the wrist coupled with flexion and extension.
Home/Work/Other Environment:
Pt. works in many different houses in his county with all different layouts including
stairs, ramps, and multiple floors. Pt’s house has 1 level and has 3 steps going into the
front door with no railing.
Family health history:
Pt. has no notable family health history.
Social/Cultural history:
Pt is not religious and does not participate in any cultural traditions.
Patient goals:
Pt. will work the normal 9-5 shift without R wrist pain going above a 2/10.
Pt. will sleep through the night at least 8 hours without waking pains in R
forearm.
Pt. will experience lessened R wrist pain at a 2/10 with bowling for <2 hours.
OBJECTIVE EXAMINATION:
Systems Review/Screen: (Use laminated Systems Review form)
HR: 77 bpm RR: 12 bpm BP: 122/72 taken on L arm in sitting Edema: n/a
Other significant findings:
Pt documents fear that work/activity will increase symptoms.
Tests and Measures:
Balance:
Pt. demonstrated no balance deficits.
Standardized Outcome Assessments:
QuickDASH – scored a 55% indicating a loss of ability in activities
Other:
ASSESSMENT (EVALUATION):
PROBLEMS LIST (Include impairments, activity limitations, and participation
restrictions):
R lateral forearm and wrist pain during sleep
R lateral forearm and wrist pain during work
Unable to pick up kids
Unable to bowl with friends
Unable to flex/pronate wrist without pain
maudsley’s test on the R side. This indicates R lateral elbow epicondylitis and carpal
tunnel syndrome. This has significantly affected the patient’s ability to complete hobbies
without pain including gardening, cooking, wood bowl turning, bowling, and playing
with kids. This is also greatly impacting Pts work efficiency due to the pain slowing him
down. This pt would benefit from physical therapy to address all previously stated
deficits, so that the pt can return to prior level of functioning.
PT Diagnosis:
Lateral epicondylitis right elbow, carpal tunnel syndrome, right upper limb, pain in right
forearm
Rehab Potential/Prognosis:
Good. Pt. has great attitude and wants to improve to get back to working efficiently.
GOALS:
Short-term (to be achieved in 4 weeks):
1. Pt. will shift work to uninvolved hand/wrist at least 3 hours a day to give involved
hand/wrist time to rest and reduce inflammation so that pt can progress to
therapeutic exercise.
2. Pt. will follow HEP every day, performing all reps and sets to reduce
inflammation of agitated tendons and to improve strength so that he is able to get
back to work.
3. Pt. will be able to advance MMT of 3/5 for flexor carpi radialis to a 4/5 within 4
weeks to improve strength for ADLs including bowling and working with
wrenches.
3. Pt will be able to work a full 9-5 shift with normal efficiency/speed (typically 3-4
houses a day).
PLAN OF CARE:
PT Frequency: 1 hour a day, 1x a week for 8 weeks (25FEB22-15APR22)
Plan of Care Interventions:
Modalities: Ice
Functional Activities: wrist flexor strength, Therapeutic exercise, Therapeutic activities,
Body mechanics/posture ed.
The treatment plan will strongly be focused on reducing tendon and nerve inflammation
by rest and ice. The treatment will also include education on proper wrist braces and
modalities to soothe pain. Therapeutic exercises will be prescribed to strengthen targeted
muscle weaknesses. Will reassess in 4 weeks.
Evidenced-Based Practice
Implications for your I used ice, rest, and a wrist brace for my initial
Therapist Name: ___Anja Bliss____
Lab (AM/PM): __________PM_____
PTH 633 FORM B: INITIAL SOAP Note Documentation Template Group (A/B): __________B______
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clinical decision-making intervention and this article supports the use of those for
lateral epicondylitis.
Ice over elbow pain for 10-15 minutes, 4-5x a day, every day of the week.
Using the pillow like this will prevent excessive wrist and arm curling while sleeping.