PTH 633 SOAP Note Template THERAPIST NAME: Lauren Wu

Page 1

ICD-10-CM Code: M77.l 1, G56.01

~
Patient Name: Ms. Abbey Jones
Date of Service: 03/18/16
r ~
BACKGROUND INFORMATION:
Referral Source: Dr. Johnson Mi11 Vi
ljJ 1wv- p ' 1f~
d~cy ~
Referring Diagnosis: Diffuse R Forearm and Wrist pain ,
Treatment Requested: Evaluate and Treat C
Other Referral Information: Radiographs of elbow, wrist, and hand negative. Pt is 35 y.o. r~
...__
SUBJECTIVE:
Current condition: Pt presents with pain in R forearm and wrist. Pt reports 9am iu
.furearm a11d. wrat,. dropping objectsfinability to grip tools has been affecting her work at
her carpentry/cabinetry business. Pain is achy, worsens over course of the day, is "hot
and burning" after work, and tends to be localized in the upper 1/3 of the lateral forearm
but occasionally "comes down the arm." Current pain is 7110 at worst and 3/10 at best. Pt
reports pain as gradual onset over past 2-3 months, but worsened after beginning a
pottery class 1.5 wks. ago. Pt also experienced tingling and numbness in the palmar side
of her R hand, specifically first three digits, 2-3 days after beginning pottery class.
Numbness and tingling persists, especially c tasks involving a lot of wrist movement. Pt
i~~t. Pt has not tried methods to alleviate pain besides medication but
notes that pain is better c rest.
Prior level of function: Pt able to tolerate whole work day at carpentry/cabinetry
business c some pain but no rest breaks. Pt able to use tools, cook, clean, pick up objects,
garden, play c young kids, and participate in bowling leagues pain or dropping objects.
Pt able to participate in bowling league 2x/wk for 2 hrs, and pottery class lx/wk for 2 hrs.
Current Functional status/activity/participation level: Difficulty c work-related
activities involving repetitive movement or gripping tools, such as hammering, sanding,
sawing. Pain causes pt to frequently drop objects or slows her work productivity. Pt also
has difficulty c basic ADLs such as cooking, holding pots and pans, chopping vegetables.
Pain interrupts family time, such as picking up and holding her two young children. Pain
disrupts hobbies such as bowling, making bowls and using clay in pottery class, and
using garden tools and watering cans in her garden.
Patient goals: Primary goal is to decrease pain to restore work productivity, be able to
hold tools and other objects s dropping, continue bowling league, pottery class, and
gardening, and be able to play c kids s pain.
Employment status/setting: Pt owns carpentry/cabinetry business of 10 yrs. c husband,
making and finishing cabinets. Works approximately 9 hrs/day, 7x/wk. Pt reports primary
source of income through business.
Medical/Surgical history; general health status: Pt denies any significant medical hx.
Pt does not smoke, and occasionally consumes ETOH 1-3x/wk.
;J ,
Current medications: Advil 200 mg 4-6x/day. ~
Fa~ly health his~ory: Pt de~es any significant family medic~l hx.
Social/Cultural history: Pt lives c husband, 1 y.o and 3 y.o children.
& f-.Q. ' /
 PTH 633 SOAP Note Template THERAPIST NAME: Lauren Wu
Page 2

OBJECTIVE: 1
EXAMINATION FINDINGS: ())r!flV
I

Systems Review: a. . ,Jv

Cardiovascular/Pulmonary: All vitals taken at rest, seated in chair. HR: 52 bpm. BP:~
102/62. RR: 9 breaths/min. Integumentary: Slightly warm to touch. Musculoskeletal: Ht:
5'3" Wt: 110 lb. Body type mesomorph. Gross screen of cervical-spine, shoulder, elbow,
wrist and hand AROM are WNL. End-range AROM for pronation, wrist
flexion/extension reproduced pain in upper lateral R forearm. End-range AROM for wrist
flexion also reproduced numbness and tingling in palmar side of first 3 fingers of R hand.
Gross screen of MMT for L UE WNL. For R UE, weakness in pronation, wrist J(
flexion/extension, and grip strength. Neuromuscular: Not impaired. ~~ ' /~ 11>
Communication/Affect/Cognition: Not impaired. {fk "'-l"'M.trcik~ ~
Observations, Tests and Measures: fl ()Jr' 4/0 ..
n I MW ~rl 6lt.

General Anthropometric Observations/Posture: Swelling in ximal 113 R forearm. v~ I

Girth measurement 2 in distal to R lateral epicond le 23 . All others WNL. Inspection
and Palpation: TIP to R lateral epicondyle and EM wa swelling present, slightly in
anatomical snuffbox. Neurological/Sensory: Light touch and sharp/dull testing impaired
.t.J;,fll, in median nerve distribution on R side. Temp ature ensation not impaired. Joint ROM:
U;{'~'1, Cervical spine, bilateral shoulder, e ow, wrist and hand ROM all WNL. Muscle
,Q.~; 1. , Length/Flexibility: Not t~sted on this date. Strength/MMT: L ~ WNL. ?rip streng~? 28

~
~ kg measured - Jamar gnp dynanometer RUE WNL except wnst extens10n (4/5), 1
~,JP igit CMC adduction and flexion (4/5), 2d and 3rd digit MCP flexion (4/5), and grip
~, dJ"/ _,""1 strength20 kg. Weakness may b 2/2 o ain. Special Tests: Cozen's, Mill' s, Phalen ' s
0 ~~Reverse Phalen's, median nerve T, an me 's at carpal tunnel all positive in RUE.
X -JJ'fl\ Pronator Teres Syndrome test, Finkelstein's, and Radial nerve ULTT all negative in R
\ 'oVI ~~ UE. Gait: Not impaired. Functional Mobility, Balance: Not impaired. Standardized
"--\ ~ "1~v- Outcome Assessments: Pt scored 43% on Quick DASH, with scores of 56% on work
'{\O ~ {~ 3 . module and 50% for sports/performing arts module.
#~ IN~W~~: ~~
~
\)
Discussed recommended interventions, risks, and benefits with pt and obtainedjnformed
consent. Soft-tissue mobilization, ice massage, stretching, and median nerve glide were 7 --
performed to decrease swelling, inflammation, and pain. With pt in supine, performed
gentle STM for 8 min. to proximal Yi of lateral R forearm, along muscle fiber orientation
in distal-proximal direction. Pt responded well to STM, reported feeling slightly tender
but not painful. Applied ice massage to proximal 1/3 of lateral R forearm as well as the
distal wrist/carpal tunnel, using circular motions and gentle pressure for 3-4 min. at each
site or until anesthesia.{Pt 's skill had slight erythema in response to i~nt other.vise
-tolerated modality wsll:-Stretched wrist extensor muscles, 10 reps of 45 s hold with 30 s
rest in between. Performed stretch with pt in supine, abducting R shoulder between 70-
900, extending R elbow, slightly pronated forearm, and fully flexing wrist c gentle
pressure, or enough pressure just before reaching onset of pain, tingling, and numbness.
From this position, performed median nerve glide for 3 min. by gently oscillating
~~

between full flexion and 30 extension. Pt responded to stretch and nerve glide well.
Educated pt on ceasing work and leisure activities to provide adequate rest for current
stages of pain and inflammation, however, recommendations are to decrease activitie~ Jfi<i'::;p'' . ..A

\\ WHL" SA'/'> M-\-11")--"\ o.,W ~ ~ rtf~f, st#

~ ~ ~'40--\-~. '(~
PTH 633 SOAP Note Template THERAPIST NAME: Lauren Wu
Page 3

and incorporate rest breaks rather than stop completely due to income dependence on
work. Educated pt on taking rest break be/hr for 5 min. at work, as well as having
husband temporarily take on more carpentry/cabinetry work. Educated pt on modifying
tool use, including using tools bilaterally rather than unilaterally, training shoulder
muscles to drive and power arm movements rather than at the elbow, and increasing tool
circumference using padding or a towel to increase grip size and decrease force needed to
grip tools. Same recommendations for household objects. Also recommended splinting at
the R forearm to unload muscle tension from bony attachment, and splinting at the R
wrist at night to keep in neutral/slightly flexed position to reduce irritation and
compression of the median nerve. Recommended decreasing time at pottery class to 1 hr.
instead of 2 hrs/wk, as well as decreasing bowling time from 2x to lx/wk for 3-4 wks.

ASSESSMENT:
Summary-Clinical Impressions: Pt presents with pain, swelling, and inflammation of Jo.-rY
the upper 113 of lateral forearm, TIP on R lateral epicondyle, and weakness )l:t pain :) rt- ~
0

during MMT of forearm pronation, wrist extension, and grip force. Pt also presents with
tingling and numbness during wrist flexion/extension. Positive tests confirmed / .~
involvement of lateral epicondyle and carpal tunnel. Pt maintains vigorous work schedule (IJ~
and many leisure activities, which include little to no rest breaks and several repetitive [;'/-~
activities that aggravate symptoms. Decreasing pain is first priority for primary
interventions, while increasing wrist and hand strength will be secondary.
PT Diagnosis: Acute R Lateral Epicondylitis and acute R Carpal Tunnel Syndrome. ~
Prognosis: Pt has good rehab potential and realistic goals. High motivation to return to
work, continue with leisure activities, and maintain quality family life. Due to income ~
dependence on and desire to maintain reputation of personally-owned business, pt's Ar
recovery may be slightly slower than expected. Pt will benefit from PT in order to t{ ~lj!IV~
decrease pain, inflammation, numbness and tingling and prevent future flare-ups via s e l l / /
management of symptoms, incorporating frequent rest breaks, and modification of
objects and body mechanics for work and leisure activities.

PROBLEMS:
Body Structure/Function Alterations: Activity Limitations/Participation
Restrictions:
1. Pain, swelling, and inflammation in upper 1. Working at carpentry/cabinetry job
1/3 of lateral R forearm, in CEM wad
2. Inflammation and tenderness at R lateral 2. Frequently dropping objects and tools
e icond le durin work, cookin , and cleanin
3. Inflammation of wrist flexor tendons in 3. Difficulty participating in bowling
carpal tunnel, irritating median nerve and league, pottery class, and gardening s pain
causin numbness and tin lina
4. Weakness in wrist flexors/extensors, and
muscles for o osition and
 PTH 633 SOAP Note Template THERAPIST NAME: Lauren Wu
Page4

GOALS:
Short-term: To be achieved in 2 wks:
1. Upper R forearm pain will decrease from 7/10 to 3/10 to allow pt to work or
participate in leisure activities up to 1 hr. before break or rest.
2. Upper R forearm swelling will decrease from 23 cm to 22 cm to decrease pain
and inflammation to allow pt to work or participate in leisure activities.
3. Grip strength in R hand will increase to 24 kg in order to decrease number of
objects dropped during work or leisure activities.
4. Number of objects dropped each day will decrease by 50%.
5. Decrease NSAIDs for pain management to 2x/day or fewer.

Long-term: To be achieved in 4 wks:

1. Upper R forearm pain will decrease to 0-1/10 to allow pt to work or participate
, in leisure activities up to 3 hrs. before break or rest.
.~ ~ Grip strength in R hand will increase to 28 kg in order to maintain adequate
~ l_ streng for holding objects.
~ \Q-r 3. u~ber of objects dropped each day w~ decrease by 100%.
4. Pt will be able to perform HEP s PT cuemg.
5. Pt will be able to implement self-management strategies such as stretching,
icing, resting, and splinting, to prevent future flare-ups.
6. Eliminate NSAIDs for pain management.

PLAN OF CARE:
Pt will be seen BIW x 4 wks. for initial course of outpatient PT. Program includes STM,
cold modalities, therapeutic stretching, nerve glide, and education on object modification,
body mechanics modifications, frequent rest breaks, forearm and wrist splinting,
{j ~ ~ reductions in volume of leisure activities. Will reevaluate pt progress weekly and
V t ?/(_ progress program as necessary to focus on strengthenin .
 Lauren Wu
HEP for Mrs. Abbey Jones
DOS 3/18/16

Wrist Extensor Stretch

Sitting or standing, st raighten out R arm forward, palm face downward. Point fingers down
toward floor and use L hand to push on back of hand to exert gentle pressure. Feel stretch on
backside of arm muscles and wrist. Hold for 30 s. Repeat 3x with 30s rest in between. Repeat 3x
daily.

Median Nerve Glide

Lie down on back wit h R arm straightened out to side. Gently and slowly bend wrist back and
forth approximately 130 degrees in full flexion (toward palm) and slight extension (toward back
of hand). {See drawing for reference). Repeat 3x daily for 1 min.

Ice massage/Ice pack

Apply ice {frozen dixie cup of water) to upper forearm and gently apply pressure to muscle
while moving in circular motions. Continue 3-5 min or until numb, at least lx daily after work.
Repeat throughout day as necessary. Additionally, apply ice pack (or frozen bag of vegetables)
around wrist for 8 min or until numb at least lx daily. /
Kasundra GM, Sood I, Bhargava AN, et al. Carpal tunnel syndrome: analyzing efficacy and utility
of clinical tests and various diagnostic modalities. Journal of Neurosciences in Rural Practice.
2015;6(4):504-510.

Abstract

Background:

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, but not adequately
studied in India.

Objectives:

To study clinical tests, nerve conduction studies (NCS), ultrasonography (USG), and magnetic
resonance imaging (MRI) in diagnosing CTS.

Materials and Methods:

We diagnosed CTS in 54 patients (93 hands) out of 60 screened patients with symptoms
compatible with CTS, including 19 control patients (23 hands). We conducted provocative tests
and calculated Boston Carpal tunnel Questionnaire (BCTQ) symptom (S) and function (F)
scores. NCS positive patients were classified into mild, mild-to-moderate, moderate, severe, and
all-CTS groups. Median nerve anteroposterior, transverse, circumference (CIR), and cross-
sectional area (CSA) at inlet (I), middle (M), and outlet (0) each was measured by USG in all
patients. MRI was done in 26 patients (39 hands).

Results:

Phalen, hand elevation and pressure provocation tests had higher sensitivity, Tinel's test had
higher specificity and tethered median nerve and tourniquet tests had low sensitivity and
moderate specificity. USG had low sensitivity but high specificity, and MRI had moderate
sensitivity. USG in patients compared to controls was significantly abnormal in CSA-I, CIR-I,
and CSA-0. Significant correlation was found between BCTQ-S and NCS and BCTQ-S and
CIR-0. CIR-M, CIR-0, CSA-M, and CSA-I had correlation with NCS. MRI was significant in
moderate and in moderate + severe groups combined and associated pathologies were detected in
59% patients.

Conclusion:

NCS remain gold standard but USG and MRI help increase sensitivity and detect mass lesions
amenable to surgery.

/
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IMPAIRMENTS Abilities Limitations Abilities Restrictions
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ENVIRONMENTAL FACTORS

INTERNAL EXTERNAL

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-~-. QuichDASH oos
3/1 '6/lb
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.
(:Le:)
NO MILD MODERATE SEVERE
UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. Open a tight or new jar. 1 2

0 4 5

2. Do heavy household chores (e.g., wash walls, floors). 1 "'2) 3 4 5

3. Carry a shopping bag or briefcase. 0) 2 3 4 5

4. Wash your back. 1 ';2\ 3 4 5

5. Use a knife to cut food . 1

0 3 4 5

6. Recreational activities in which you take some force

or impact through your arm, shoulder or hand
(e.g., golf, hammering, tennis, etc.).
1 2 3
0 5

QUITE
NOT AT ALL SLIGHTLY MODERATELY EXTREMELY
A BIT

0
7. During the past week, to what extent has your
arm, shoulder or hand problem interfered with
your normal social activities with family, friends,
1 2
/~v 5

neighbours or groups?

NOT LIMITED SLIGHTLY MODERATELY VERY

UNABLE
AT ALL LIMITED LIMITED LIMITED

8. During the past week, were you limited in your

work or other regular daily activities as a result
of your arm, shoulder or hand problem?
1 2 3
8 5

Please rate the severity of the following symptoms

in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME

9. Arm, shoulder or hand pain. 1 2 4 5

10. Tingling (pins and needles) in your arm,

1 2 4 5
shoulder or hand.

SO MUCH
NO MILD MODERATE SEVERE DIFFICULTY
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THATI
CAN'T SLEEP

11. During the past week, how much difficulty have

you had sleeping because of the pain in your arm ,
shoulder or hand? (circle number)
1
0 3 4 5

/
QuichDASH DISABILITY /SYMPTOM SCORE = (fsum of n responseS)]-1\x 25, where n is equal to the number
of completed responses. n \l J )
'7~)
A QuichDASH score may not be calculated if there is greater than 1 missing item. (fi';--l ~ r;e;~
 f QuichDASH

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including
homemaking if that is your main work role).
Pleasei ndicatewhatyourjob/workis: CCvpchi-0 I cvJ-JiV\Qt (...l.Q..10l cyh-QN l \A1Ccd-f\VJ \ S,\/UJ(
v
0 I do not work. (You may skip this section.)
Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty: NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for your work? 1 2 4 5

2. doing your usual work because of arm,

shoulder or hand pain?
1 2 3 0:) 5

3. doing your work as well as you would like? 1 2 Q2 4 5

4. spending your usual amount of time doing your work? 1 2 4 5

SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or
sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is
most important to you .
Please indicate the sport or instrument which is most important to you:_~b~G_'v._IJ_(_-l_N---;,---------------
j
0 I do not play a sport or an instrument. (You may skip this section .)

Please circle the number that best describes your physical ability in the past week.

Did you have any difficulty: NO MILD MODERATE SEVERE

UNABLE
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for playing your

instrument or sport? 1 2 QJ 4 5

2. playing your musical instrument or sport because

of arm, shoulder or hand pain?
1 2 (3) 4 5

3. playing your musical instrument or sport

as well as you would like?
1 2 3
0 5

4. spending your usual amount of time

1 3 4 5
practising or playing your instrument or sp )

I
IM
Institute Resea rc h Excellence
SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by for Work & Advancing Employee
4 (number of items); subtract 1; multiply by 25. Health Healt h

An optional module score may not be calculated if there are any missing items. C INSTITUTE FOR WORK & H EALTH 2006. ALL RIGHTS RESERVED