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Assignment of Documentation

S.G. is a 40-year-old female office worker referred to physical therapy for lateral epicondylitis. She reports constant moderate to severe pain in her right elbow preventing tennis. Examination reveals tenderness and mild swelling at the lateral epicondyle with pain on resisted wrist extension. The goal is to reduce pain within 2 to 4 weeks. The plan is for her to rest for 14 days and continue NSAIDs until symptoms decrease from moderate to severe to moderate to mild.

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nayab kanwal
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29 views2 pages

Assignment of Documentation

S.G. is a 40-year-old female office worker referred to physical therapy for lateral epicondylitis. She reports constant moderate to severe pain in her right elbow preventing tennis. Examination reveals tenderness and mild swelling at the lateral epicondyle with pain on resisted wrist extension. The goal is to reduce pain within 2 to 4 weeks. The plan is for her to rest for 14 days and continue NSAIDs until symptoms decrease from moderate to severe to moderate to mild.

Uploaded by

nayab kanwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Name: Humaira Bashir

program: MS PPT 1st semester

Subject: Rehab education ethics and documentation


Assignment;
You are a therapist in an outpatient practice and are working with a patient who has a diagnosis of
lateral epicondylitis.

S. G. is a 40-year-old female office worker. She has been referred to therapy with a diagnosis of lateral
epicondylitis. S. G. reports of constant moderate to severe pain at her R lateral elbow that prevents her
from playing tennis. The pain started about 1 month ago, the morning after she spent a whole day
pulling weeds, and remained unchanged in severity or frequency until 3 days ago. She reports a slight
decrease in pain severity over the last 3 days, which she associates with starting to take a nonsteroidal
anti-inflammatory drug (NSAID) prescribed by her physician. She has had similar symptoms previously
after gardening or playing tennis, but these have always resolved within a couple of days without any
medical intervention. Objective examination reveals tenderness and mild swelling at the right lateral
epicondyle and pain without weakness with resisted wrist extension. All other tests, including upper
extremity sensation, range of motion, and strength, are normal.

You should create a plausible situation, including goals, subjective, objective, assessment, and plan.
Write a session SOAP note for your patient based on the case information provided

Session Soap Note


Name: S.G. a 40-year-old female office worker.
Current condition: lateral epicondylitis
Goal:
reduce pain in 2 to 4 weeks

Subjective: pt. reports of constant moderate to severe pain at her R lateral epicondylitis that prevents
her from playing. The pain started about 1 month ago. She reports a slight decrease in pain severity over
the last three days.

Objective: objective examination reveals tenderness and mild swelling at the right lateral epicondyle
and pain without weakness with resisted wrist extension

Assessment: Pt reports a slight decrease in pain severity over the last 3 days, which she associates with
starting to take a nonsteroidal anti-inflammatory drug prescribed by her physician. She has had similar
symptoms previously after gardening or playing tennis, but these have always resolved within a couple
of days without any medical intervention.
Plan of care: she should take rest for at least 14 days and continue taking NSAIDs prescribed by her
physician until her symptoms i.e., swelling, tenderness and pain decreases from, moderate to severe
stage to moderate to mild stage

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