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 Diagnosis (ICD-10): Lateral epicondylitis right elbow M77.11, carpal tunnel syndrome, right
upper limb G56.01, pain in right forearm M79.631

Medical Diagnosis (ICD-10): M79.631 Right forearm pain

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:

General Anthropometric Observations/Posture:

Pt has L shoulder higher than R shoulder but is R handed. Pt is a mesomorph and has
good sitting and standing postural alignment.
Inspection/Observation:
 Therapist Name: ___Anja Bliss____
Lab (AM/PM): __________PM_____
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No signs of edema, ecchymosis, or swelling.

Neurological/Sensory:
 Dermatomes – no sensory loss
 Myotomes – no motor loss
ROM:
All gross UE ROMs were WNL*
*There was pain at the end of wrist flexion, pronation, elbow extension, and ulnar
deviation.
Muscle Length/Flexibility:
There were no signs of adaptive muscle shortening.
Strength/MMT:
Pt. has full bilateral strength with all MMTs except R flexor carpi radialis – 3/
Palpation:
Pt. has soreness just distal to R lateral epicondyle and soreness over palmer side of R
wrist.
Joint play assessment:
Pt’s R elbow and R wrist were assessed with no functional joint deficits. Only pain
caused by neurological compression and tendon inflammation.
Special Tests:
 R Carpal Compression Test: +
 R Tinel’s Sign over Carpal Tunnel: +
 R Mill’s Test: +
 R Cozen’s Test: +
 R Maudsley’s Test: +
Gait:
Pt’s gait was assessed, and no deficits were found. Gait was found to be symmetrical and
no assistive devices were used.
Functional Mobility:
Pt has a slower time cooking and taking care of the garden due to R forearm pain of 8/10
with these activities.
 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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Balance:
Pt. demonstrated no balance deficits.
Standardized Outcome Assessments:
 QuickDASH – scored a 55% indicating a loss of ability in activities
Other:

INTERVENTIONS (must include statement of informed consent (review of POC

and consent to treat) and patient participation in goal setting):
Pt. provided informed consent after extensive ed. On dx and plan of care. Pt. participated
in goal and plan writing. Pt was fitted for proper wrist extension brace and educated in
how to wear it while participating in ADLs. Pt was also educated on proper icing
techniques and directed to ice lateral epicondyle tendons on and off over the course of the
next week to reduce inflammation of tendons. HEP included icing and rest this week
coupled with sleeping with a pillow between body and arm to prevent excessive arm and
wrist curling.

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

Summary-Clinical Impressions (Tie the impairments to activity limitations and

participation restrictions and justify the need for skilled physical therapy):
Pt presents with R wrist and R lateral forearm pain. Pt has R flexor carpi radialis
weakness of 3/5. Pt feels pain and sometimes tingling with wrist flexion, pronation, and
ulnar deviation. Pt has normal dermatome and myotome distribution. Pt tests positive for
carpal compression test, tinel’s sign over carpal tunnel, mill’s test, cozen’s test, and
 Therapist Name: ___Anja Bliss____
Lab (AM/PM): __________PM_____
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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.

Long-term (to be achieved in 8 weeks):

1. Pt will have all R wrist and forearm pain reduced to a 1/10 or lower to perform
previous hobbies and work functions.
2. Pt will be able to grasp heavy objects in affected hand/wrist with 1/10 or lower
pain so that pt can get back to his bowling league and continue to participate in
the community.
 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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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.

Manual Therapy Techniques: STM, Myofascial release techniques

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.

___Anja Bliss_ SPT

Evidenced-Based Practice

AMA Citation Sevier, T.L., Wilson, J.K. Treating Lateral

Epicondylitis. Sports Med 28, 375–380 (1999).
https://doi.org/10.2165/00007256-199928050-
00006

Link to article (or doi) doi.org/10.2165/00007256-199928050-00006

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.

Home Exercise Program

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.