Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Characterize the location and severity of Dupuytren’s contracture(s):
Which fingers are affected (e.g., pinky, ring finger)?
Onset and progression of symptoms (gradual tightening of the palmar fascia).
Degree of finger flexion contracture (measured in degrees using a goniometer).
Functional limitations caused by the contracture (difficulty grasping objects, buttoning clothes).
Pain level (numeric rating scale).
Objective:
Physical Exam:
Hands:
Inspect for nodules (firm lumps) and cords (thickened bands) in the palm.
Assess range of motion (ROM) of the affected fingers at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.
Evaluate skin integrity and evidence of calluses over pressure points.
Neurovascular exam: Test for sensation and capillary refill in the fingers.
Assessment:
Dupuytren’s contracture involving the [name of fingers] with [degree] of flexion contracture (measured in degrees).
Consider the stage of Dupuytren’s contracture based on clinical presentation:
Early stage: Palpable nodules without contracture.
Intermediate stage: Palpable cords with mild-to-moderate contracture.
Advanced stage: Severe contracture with fixed flexion deformity.
Functional limitations due to contracture.
Plan:
Treatment options will depend on the severity of the contracture and functional limitations. Discuss the following with the patient:
Non-surgical Management (early stage):
Splinting: Night splinting to maintain finger extension and slow progression.
Hand therapy: Stretching exercises to improve flexibility and range of motion.
NSAIDs for pain management.
Surgical Management (moderate to advanced stages):
Discuss different surgical approaches depending on the severity and location of contracture:
Percutaneous needle fasciotomy: Minimally invasive procedure using a needle to break the tight bands.
Fasciectomy: Surgical removal of the thickened palmar fascia.
Risks and benefits of surgery should be weighed with the patient.
Post-operative Management (if surgery is performed):
Hand therapy is crucial for regaining range of motion and preventing recurrence.
Pain management medications.
Follow-up:
Schedule regular follow-up visits to monitor disease progression and treatment response.
Reassess finger contracture and functional limitations.
Discuss the need for further intervention (hand therapy, surgery) as needed.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding location and severity of contracture, functional limitations, physical exam findings, and treatment plan. Consider imaging studies (X-ray) in some cases. Involve a hand therapist in the care plan for optimal outcomes.